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COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />ROOM 610, COURTHOUSE <br />= 222 EAST WEBER AVENUE <br />STOCKTON, CALIFORNIA 95202 <br />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />- -. FAX (209) 9449015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />1&gure/vun /3u74//� 70,;' <br />TELEPHONE NUMBER <br />9Soz-��8� <br />BUSINESS ADDRESS acility Being Inspected) <br />7 <br />FIRE DISTRICT <br />INSPECTION DATE <br />JARRIVAL TIME <br />DEPARTURE TIME <br />INSPECTION TYPE <br />INSPECTION RESULTS <br />DOCUMENT REVIEW 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 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 />12. Hazardous Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />113. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />/Gc , ���jr ori fr 'e -W <br />REFERRALS ❑ SJ Ag ❑ SJ Env Hlth ❑ OSHA ❑ Firc ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions Must be Delivered to OES By <br />Follow Up Inspection <br />6'_(S _0Dyte <br />OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />BgRiTss Repres <br />C �} <br />tative (Print Name and Title) Lusme epresentanve (Si nature) <br />Nam f Inspector nZL� gency n Fire o. (If Appropriate) <br />Q.fcei^/ �J '©�J <br />WHITE COPY: OFS <br />PINK COPY: BUSINESS <br />REV 9/02 <br />