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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> fi STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> F FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAMW I, TELEPHONE NUMBER <br /> BUSINESS ADDRESS(F cility Being Inspected <br /> FIRE IDIISTRICT INSPECTIONTE 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 X 1 7.Facility Map Complete and Accurate <br /> 2.H DAP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/HMIvT Complete and Accurate y 1 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? 11.Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets(MSDS)On Site 112.Hazardous 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 /> REFERRALS ❑SJ Ag ❑Si Env Hlth ❑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 /> Business Representative(Print Name and Title) Busess Represe five(Signature) <br /> j2A �&Xl L2 <br /> Name f I or S G A Fire Co.(If Appropriate) WHITE COPY: OES REV 9/02 <br /> PINK COPY: BUSINESS <br />