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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> i5u HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> _ FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> t,rn l h /e <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> la ad <br /> FIRE DISTRICIr 114SPECTION DATE ARRIVAL TIME DEPARTURE TIME JINSPECTION TYPE <br /> LA+-h f Ihu d a --e16le-570 1 tc/ It rn Al <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 2S 17. Facility Map Complete and Accurate kv <br /> 2. HMMP/Map Easily Accessible to Employees 8. Chemical Inventory Complete and Accurate 2r <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? a 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 /> COMMENTS(Items marked"NO"above must be explained in this section) <br /> 4e, L Vl 'e <br /> W `J 5 6A ll <br /> Womly <br /> � I <br /> REFERRALS ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must be Delivered to OE S By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Re res ive(Si at i <br /> Name of Inspector A ncy Fire Co. (If Appr riate) WHITE PY: OEs <br /> PINK COPY: BUSINESS I REV 9/02 <br />