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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 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 /> BUSEE SS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRE (Facility Being Inspected) <br /> /� ' �w f /use e-0— 33 <br /> FIRE DISTRICTSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> 14(16 � L INs-a7-03 09:" I /opt <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION 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 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 Employees <br /> 5.Material Safety Data Sheets(MSDS) On Site 12.Hazardous Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand 13.Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"above must be explained in this section) <br /> REFERRALS ❑SJ Ag ❑SJ Env 111th ❑OSHA ❑Fire ❑ DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Yust be Delivered to OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> V -9-03 <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RES TS <br /> Bus' Re resentative(Print Name and Title) Busin se [i (Signature) <br /> S G kvr. M <br /> Name of Inspector `z AgencyFir o. (If Appropriate) WHITE COPY: UES REV 9/02 <br /> BUSINESS <br />