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, COUNTY OF SAN JOAQUIN <br /> 2`1:0. <br /> ao .co OFFICE OF EMERGENCY SERVICES <br /> u*r * <br /> ROOM 610, COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3969 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BU NAME 1, TELEPHONE <br /> Jack �n Bnx 9 S43- ZlS7 <br /> BUSINESS ADDRESS(Facility Being In cted) ZfPCODE <br /> 't 9 L 9 S. o Qs2 as- <br /> FIRE <br /> DIS NFLU13VNDAIP ARRIVALTIME DEPARTURETIME INS O TYPE <br /> //2 319 P /,S ? <br /> 1/ a <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH 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&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 11.Materials Being Properly Handled <br /> 5.Material Safety Data Sheets (MSDS)On Site 12.Materials Properly Stored and Labeled <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 /> X cf C z <br /> 2- <br /> dij 6,t Mee <br /> REFERRALS (FOR OES USE ONLY) ❑SJ Ag ❑SJ Env Hlth []OSHA Fire Air Dist <br /> INSPECTION FOLLOW UP INFORMATION <br /> Corrective Actions Must Be Delive7=low 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) Business Represen - <br /> ^l ' ^ CCI <br /> Name Ingpector aid Fi Company OES <br /> 6 CANARY COPY: FIRE PREVENTION REV 11/96 <br /> 2/ L Z- PINK COPY: BUSINESS <br /> O S HMI(11M) <br />