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COUNTY OF SAN JOAQUIN <br /> �p4ulN' C OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> c�Cicbn`'J BUS. (209)468-3969 FAX(209)9449015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> < < ( Ghr <br /> BUSINESS ADDRESS(Facilty Being Inspe ted) ZIPCODE <br /> FIKEa. rte � <br /> DISTRICT INSPE IONDATE ARRIVAL TIME DEPART TIME INSPECTION TYPE <br /> ti� _e>> I V <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 Y <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 k' <br /> 4.If Business is a Hazardous Waste Generator, �/ 10. Plant Operations Appear Safe <br /> are Hazardous Waste Manifests On Site ^ 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 /> � atVck4 A 4(eGACjG VO15(4 <br /> w <br /> U!I <br /> REFERRALS (FOR OES USE ONLY) ❑SJ Ag E:]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 /> R- ;2_ j -a.Z <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business Representative(Sig re) <br /> .7 --a-04 <br /> Name of Inspector and Fire Company WHITE COPY: OES <br /> CANARY COPY: FIRE PREVENTION REV 11196 <br /> PINK COPY: BUSINESS <br /> OES-HM t (9100) <br />