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P ,-14 COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> 'v <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 /> L43 a B C O Vt't A-VI 14 'fav 4-sz 9 <br /> BUSINESS 1,DDRESS(Facility eing�Ipspected) <br /> FIRE DISTRICT INSPECIfION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> V,c7 c_k ,. Z Z/07 I f II -LO Co•^ 1,'a K c <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site V 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 <br /> are Hazardous Waste Manifests On Site? 11.Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets (MSDS) On Site 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 /> Xc, cL 1r O Q © t - <br /> �t�ZtS 1. <br /> e__ Oyy <br /> REFERRALS 0 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 Rep nt 11ve(Print ame and Title) Business epresentative(Signature) <br /> w=� b 104-O,- r <br /> Na I spectog A ency, Fire Co. (If Appropriate) ITE COPY: OES <br /> O��✓ 7— PINK COPY: BUSINESS I REV 9/02 <br />