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r' 2 <br /> No 1423 $$ <br /> SAN JOAQUIN COUNTY OFFICE OF EMERGENCY SERVICES <br /> HAZARDOUS MATERIAL DIVISION <br /> INSPECTION FORM <br /> INSPECTION DATE ��r' ZQ / AkkIVAL TIME 'C>U <br /> BUSINESS NAME tn: t ----___ DEPARTURE TIME <br /> L x`g43PHONE_ --3 �1=-3sZ------ ------ <br /> --- _ <br /> BUSINESS ADDRESS � v - -- --------- <br /> FORM =- '_ �szlC _fit__ I—,c_(1'------------- <br /> FORM TYPE: -----SHORT _ Y _LONG r -----FARM ------------- <br /> _____EXEMPT <br /> A. ADMINISTRATIVE_INFORMATION <br /> Yes No Comments <br /> 1 . Business Flan available on-site _1s <br /> Notification Information current ✓� ------"--------- <br /> 1. <br /> Staff Responsibilities current ----------------------- <br /> 4. Plan signed/dated `j --- ------------------------ <br /> 5. Evacuation Procedures posted <br /> - ---------- <br /> 6. 1/8 Mile Land Use noted % --- _ta c �4ot(1 <br /> 7. Safety/Spill/Monitoring Equipment .. v7 , _ ----`-------------- <br /> 9. Clean-Up Company Phone # osted _ --- <br /> _ ---- ---- --- <br /> 4. Spill `Containment Procedures -(�-lI`12!L:4 - <br /> 10. Nature of Business --- <br /> 11. Facility Diagram w/ Chemicals noted -— S -------- <br /> 1�. Topographical Diagram ✓ --- Cy��_ , - - LLV_!kL�yfc --(r <br /> ___ <br /> 13. Employee Training Records f ------------------------ <br /> 14. Waste Generator --- --- ------------------------ <br /> 15. EPA Number for waste generators J ------- <br /> ----------- <br /> 16. Chemical Inventory complete f ----------------------- <br /> --- --- ------------------------ <br /> B. HAZARDOUS-MATERIAL-SAFE STORAGE AND HANDLING INFORMATION <br /> -------- ------------------------------------- <br /> Yes No Comments <br /> 1 . Material Safety Data Sheets on file ✓ <br /> Chemicals properly labelled f _ ---------------------- <br /> 3. Chemicals properly stored ------------ <br /> 4. <br /> -- - ---- <br /> 4. Safety Hazards --- ✓ 5 � it`d �� � - a� <br /> 5. Housekeeping in order - --------------- <br /> 6. <br /> - ------6. Secondary Containment --_ ✓ � '-� �"-"-i=1t� '� <br /> C. CO_MPLIANCE_VERIFICATION <br /> (_ <br /> Inspector 1,.� . <br /> ---- ------ Date _�/C <br /> Approved -j- <br /> s ----- o Follow-up Inspection Date <br /> -----------L---- <br /> Business Representative GL 2 � &Pw------------- TitlerPaq1Pw� <br /> c ( rint) <br /> —.a T------ <br /> (signature) <br /> white - oes <br /> canary - applicant <br /> pink - file <br />