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1 <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 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 —7// TELEPHONE NUMBER <br /> tei /b <br /> BUSINESS ADDRESS (Facil1 Being Inspected) <br /> Il¢ surd <br /> FIRE DISTRICT INSPECTION DATE IVAL DEPARTURE TIME INSPECTION TYPE <br /> LIC+h -1 -� o'R'� I Cla fad e w <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YE NO FACILITY INSPECTION YES N <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 and Accurate <br /> 3.Bus ID Page/IIIMMP Complete and Accurate R 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? 1 11.Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets(MSDS)On Site 12.Hazardous Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand 13.Soil and Facility Appear Non-Contaminated <br /> HE , <br /> COMMENTS (Items marked"NO"above must be explained in this section) <br /> REFERRALS ❑SJ Ag ❑SJ Env Mth ❑OSHA ❑Fire ❑DA ❑ <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 /> Busing Representative(Print Name and Title) s Represe ve(Signattl�e) <br /> Z /` <br /> Name of Inspector , ^ Agency Fire Co.(If Appropriate) WHITE PY: <br /> 1,` PINK COPY: BUSINESS I REV 9/0 <br />