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'l <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> f 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 s TELEPHONE NUMBER <br /> 1 h cc rol wa C <br /> BUSINESS ADDRESS(Facility Being 10pJaedl <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TI DEPARTURE TIME INSPECTION TYPE <br /> I'nan4e c I [ it 3 � LID J <br /> INSPECTION RESULTS 5( <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 7.Facility Map Complete and Accurate E <br /> 2. HMMPINIap Easily Accessible to Employees S.Chemical Inventory Complete and Accurate <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? 11.Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets (MSDS) On Site 112.Hazardous Materials Properly Stored ani 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 /> ,i <br /> •E <br /> d <br /> ,I <br /> Y <br /> ,t <br /> .i <br /> REFERRALS ❑S7 Ag ❑ SS 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 /> ;l <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Business presentative(Signature) <br /> LCA AP 1,4A�, � ! <br /> Name of Inspector Agency Fire Co. (If p opriate) WHITE COPY: OES <br /> PINK COPY: BUSINESS REV 9102 <br />