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COUNTY OF SAN JOAQUI - <br /> �o�. ........� <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> t 'r, BUS. (209)468-3969 FAX(209)9449015 <br /> 'I FGP'�P <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility Being Inspected) ZIPCODE <br /> FIREDISTRICT INSPECTION DATE ARRIVALTIME DEPARTURETIME INSPECTION TYPE <br /> /V/u/c le/o <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1. Business HMMP/Inventory On Site 7. Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8. Chemical Inventory Complete&Accurate <br /> 3. Bus ID Page/HMMP Complete and Accurate 9. Employees Familiar with HMMP <br /> 4.If Business is a Hazardous Waste Generator, 10.Plant Operations Appear Safe - <br /> are Hazardous Waste Manifests On Site y 11.Materials Being Properly Handled �. <br /> 5. Material Safety Data Sheets(MSDS)On Site ✓ 12.Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand 113. Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked "NO" above must be explained in this section) <br /> %uc074 /' i <br /> REFERRALS (FOR OES USE ONLY) ❑SJ Ag ❑SJ Env Hlth OSHA [:] Fire ❑Air Dist <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must Be Delivered To OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Represent a(Print Name and Title) n Businsss Re-pr_esentati Signature) <br /> / <br /> Name of Inspe for an �Jire Company WHITE COPY: OEs <br /> CANARY COPY: FIRE INKCOPY: BUSINESS <br /> ENTION REV 11/96 <br /> OES-NMI (9Po0) <br />