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F �- 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 /> Q ry?�. - FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME — TELEPHONE NUMBER <br /> rolaV <br /> BUSINESS ADDRESS (Facility Being Inspected) <br /> W <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> Lccf he, e-.4 -rte Ct 3C , I <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? n 11.Hazardous Materials Being Properly Handled by Employee a" <br /> 5. Material Safety Data Sheets (MSDS) On Site 12.Hazardous Materials Properly Stored and Labeled or <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 /> l� <br /> l Y1 <br /> REFERRALS ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Ac W ns Must be Delivered to OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> -0 61- 9 <br /> ACKNOWLEDGEMENT OFR VIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Prin me and Title) Business Re sentati 'gnature) <br /> �Nameof Inspector Agency Fire Co. (I Appropriate) WHITE COPY: OES <br /> PINK COPY: BUSINESS REV 9/0 <br />