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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> yl 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 /> Tca c are <br /> BUSINESS ADDRESS Facility Beirfg Inspected) <br /> FIRE DISTRICT INSPECTIOR DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> LZ W- � --C7 I C1q I�5- I lI )fvq ►� <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO - FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 17.Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 18.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 113.Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"above must be explained in this section) <br /> ma�j- be cel, it ic, <br /> REFERRALS ❑SJ Ag ❑SJ Env Mth ❑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 /> 'c.-- <br /> ACKNOWLEDGEMUNt OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br /> Business Represe rve(Print Name and T i Business Representativ ignature) <br /> Name of Insp7tot V Agerky Fire Co.(If Appropriat WH COPY: OES <br /> L PINK COPY: BUS] S REV 9102 <br />