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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> kel ♦1 ROOM 610,COURTHOUSE <br /> �,: 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME� TELEPHONE NUMBER <br /> Rte' ,e # 7 f�/ 1,. <br /> 76 <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> oS <br /> FIREDISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 7.Facility Map Complete and Accurate <br /> 2.HMMP/Map Easily Accessible to Employees 18.Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/HMMP Complete and AccurateEmployees Familiar with HMMP <br /> 4.If Business is a Hazardous Waste Generator, .Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site? .Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets (MSDS)On Site1112.Hazardous Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand .Soil and Facility Appear Non-Contaminated <br /> COMMENTS(Items marked`NO"above must be explained in this section) <br /> REFERRALS ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑Fire ❑ DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must be Delivered to OES By Follow Up Inspection Date_r77 <br /> Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Signature) <br /> Name o <br /> Inspector enc Fire Co.(If Appropriate) WHITE COPY: OES <br /> Alf^P � ,� PINK COPY: BUSINESS I REV 9/02 <br />