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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 /> *ev HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> Cakl GP F <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> 1 679 l-f t k uv u 'Y'F <br /> FIRE DISTRICT INSP CTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> W d � d -( -� 08 h0 -f M M <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/HNIMP 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 61 <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 <br /> (Items marked"NO"above must be explained in this section) <br /> d" <br /> CIV L s-q t vyict <br /> REFERRALS ❑SJ Ag ❑SJ Env HIth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must be Delivered to OES By Follow Up Inspection Date OES Inspecto N e Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Bust ss Representative(Print Name and Title) Business presents Si ature) <br /> � ` �J <br /> Name of Inspector Agency Fire Co.(If ppropriate) COPY: OES <br /> PINK COPY: BUSINESS REV 9/02 <br />