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r <br /> -� COUNTY OF SAN JOAQMN <br /> o.P4�IN..c OFFICE OF EMERGENCY SERVICES <br /> �• .o <br /> ROOM 610, COURTHOUSE <br /> a < 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> • c.., P BUS. (209)468-3969 FAX(209)944-9015 <br /> 4tIFORa <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> 1112 00,14,ewy <br /> BUSINESS l r SAADDRESS(Facility Being Inspected) ZIP CODE <br /> Rare-4 Jc ; 9s�9 <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <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 <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 <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 112.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 /> �6 <br /> el <br /> REFERRALS (FOR OES USE ONLY) ❑SJ Ag [JSJ 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 /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Re sentative Print Name and Title) I Business Representative(Signature) <br /> Name f Inspector and Fire Company WHITECOPY: OES <br /> CANARY COPY: FIRE PREVENTION REV 11/96 <br /> �Iq O�GLI�Q�/2— PINK COPY: BUSINESS <br /> OES-HMI (9/00) <br />