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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES RECEIVED <br />.{ ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE DEC 10 2004 <br />STOCKTON, CALIFORNIA 95202 <br />FR- a HAZARDOUS MATERIALS DIVISION (209) 468-3969 SAN JOAQUIN COUNTY <br />-- °= FAX (209) 944-9015 OFFICE OF EMERGENCY SERVICES <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />TELEPHONE NUMBER <br />BUSINESS ADDRESS (Facility Being Inspected) <br />\\\qq y C\a <br />FIRE DISTRICT <br />INSPECTION DATE <br />\ OA <br />ARRIVAL TIME <br />DEPARTURE TIME <br />1INSPECTIONTYPE <br />INSPECTION RESULTS <br />DOCUMENT REVIEW ESj NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />j 1 <br />7. Facility Map Complete and Accurate <br />2. HMMP/Map Easily Accessible to Employee <br />8. Chemical Inventory Complete and Accurate <br />3. Bus ID Page/HMMP Complete and Accurate <br />9. Employees Familiar with HMMP <br />4. If Business is a Hazardous Waste Generator, <br />are Hazardous Waste Manifests On Site? <br />10. Plant Operations Appear Safe <br />11. Hazardous Materials Being Properly Handled by Employee <br />5. Material Safety Data Sheets (MSDS) On Site <br />12. Hazardous Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />113. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />REFERRALS ❑ SJ Ag ❑ SJ Env Hlth ❑ OSHA ❑ Fire ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions Must be Delivered to OES By <br />Follow Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) /J <br />Busine s Representative (Signature) <br />Name of Inspector Agency Fire Co. (If Appropriate) <br />VEWIN. <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />I REV 9/0 <br />