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0 f <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />ti STOCKTON, CALIFORNIA 95202 <br />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />FAX (209) 944-9015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BU SS NAME <br />TELEPHONE NUMBER <br />BUSINESS ADDRE acifit Being <br />r <br />FIRE DISTRICT 1INSPECTTONDATE <br />- <br />ARRd1VkLTI9&E <br />b <br />DEPARTURE TIME <br />INSPECTION TYPE <br />INSPECTION RESULTS <br />DOCUMENTREVIEW YES NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />7. Facility Map Complete and Accurate <br />2. HMMP/Map Easily Accessible to Employees <br />8. Chemical Inventory Complete and Accurate <br />3. Bus ID Page1HMMP 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 />I/( <br />10. Plant Operations Appear Safe <br />j—T 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 />13. Soil and Facility Appear Non -Contaminated v" <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 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 <br />RESULTS <br />Business presen 'v nt Name and Title) <br />S c, h <br />��;Qcto <br />Business Representative (Signature) <br />Agenc Fire Co. (If Appropriate) <br />WHITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 9/02 <br />