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COUNTY OF SAN JOAQUIN "� "trG �' <br /> OFFICE OF EMERGENCY SERVICES MAY 12 2004 <br /> ROOM 610,COURTHOUSE biA!tvAG 3']b UA1q 4XII V I Y <br /> 222 EAST WEBER AVENUE mCE onir.r RGENCY SERVICE <br /> STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)9449015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> �4 '1= b-S,2,' <br /> BUSINESS ADDRESS (Facility Being Inspected) <br /> FIRE DISTRICT INSPECT`I`ON DATE ARRIVAL TIME DEPARTURE TIIviE INSPECTION TYPE <br /> qxovza4.4_;z10 w3o <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 j <br /> are Hazardous Waste Manifests On Site? 11.Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets(MSDS) On Site v1 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 Hlth ❑OSHA ❑Fire ❑DA ❑ <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must be Delivered to OES By Follow Up Inspection Date OES Inspector Name Performing Follow Up <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) Bus' Representative(Signatgre) <br /> Name of Inspector Agency Fire Co. (If Appropriate) WHITE COPY: OES <br /> �S a.y . 19; . PINK COPY: BUSINESS REV 9/0 <br />