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r -m <br />• <br />mr <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />ROOM 610, COURTHOUSE <br />222 EAST WEBER AVENUE <br />ri 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 />BUS SS ADDRESS (Facility Being Inspected) <br />I Ylff 4 99 <br />FIRE 9DDISTRICT <br />INSPECTION DATE <br />�/. ,2�— O r <br />JARRIVALTIME <br />/ O <br />DEPARTURE TIME <br />//,, Zr <br />INSPECTION TYPE <br />pr2LGC"e;00 <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />%/ <br />7. Facility Map Complete and Accurate <br />2. HMMP/Map Easily Accessible to Employees <br />8. Chemical Inventory Complete and Accurate r <br />3. Bus ID Page/HMMP 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 />10. Plant Operations Appear Safe <br />11. Hazardous Materials Being Properly Handled by Employee <br />5. Material Safety Data Sheets (MSDS) On Site <br />v <br />12. Hazardous Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />13. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />-oli-Or z21 r7 �u <br />REFERRALS ❑ SJ Ag ❑ SJ Env Hlth ❑ OSHA ❑ Fire ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions Must be Delivered to OES By <br />3_ io - v - <br />Follow Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />�s V., � ate; -V14 W <br />Bu si s Representative ignature) <br />Nam,Af In pector AgeeFireCo. (If ppropriate) <br />274,Wr ��� <br />I WHITE COPY: CIES <br />PINK COPY: BUSINESS <br />I REV -21 <br />