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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> {C7 , <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 /> BUSINESS NAME TELEPHONE NUMBER <br /> q(0 6 -OGS-� <br /> BUSINESS ADDRESS (Fareflity Being Inspected) <br /> crACC- <br /> FUZE DISTRLLICT INSPECTION DATE JARRIVAL TRA DEPARTURE TIME INSPECTION TYPE <br /> A1.111 /y/ q /3�0 !3"30 l�l�Lld2f� <br /> 4�4 INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1.Business HMW/Inventory On Site 7.Facility Map Complete and Accurate <br /> 2.HMMP/Map Easily Accessible to Employee 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/IIMMP Complete and Accurate L,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 Employee <br /> 5. Material Safety Data Sheets(MSDS)On Site E7112.Hazardous Materials Properly Stored and Labeled <br /> 6.Current Training Records On Hand 3.Soil and Facility Appear Non-Contaminated <br /> NTS (Items marked"NO"above must be explained in this section) <br /> AZA ar ctC <br /> µY �.O✓L <br /> /r- C—/ Gllyl le CGGc <br /> — L)5- R -rY0✓i`o1 leoC& S <br /> Ffb- ?✓o vote ro07'� 0 A re%ve , <br /> -7 — ad cf4o e 5 M 11 of Aejr nDac? :k<.- a <br /> S Gt go Co/ le P oa e_ S �I sum <br /> �- e Dade amt%- e e 2 e (/moo c( / <br /> etH� � :u / eu ger S �� av' 4e- //` y r. <br /> /4 _ /wt✓Gw r✓ <br /> Idye eT o ✓e EtioT :..r�.�:nr e✓/ '� ////d4/ <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 Inspector Name Performing Follow Up <br /> ACKNOWLEDG MENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Representative(Print Name and Title) n(1 '� Busines presentative(Signature) <br /> GA12�05 !'1 �D„ B �Ev to Slw {il <br /> Name of Inspector o L,4Agency O�J, Fire Co. (If Appropriate CO Y: OES <br /> A.e BUSIIYFSSV 9/0 <br />