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3zgk <br /> ti COUNTY OF SAN JOAQUIN RECEIVED <br /> OFFICE OF EMERGENCY SERVICES <br /> + ROOM 610,COURTHOUSE J U N -S 2005 <br /> 222 EAST WEBER AVENUE <br /> SAN JOAOUIN COUNTY <br /> STOCKTON, CALIFORNIA 95202 OFFICE OF EMERGENCY SERVICE <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> 2 - FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS N TELEPHONE NUMBER <br /> 131 <br /> BUSINESS <br /> BUSINESS ADDRESS j'. (Facillity Being Inspected) <br /> . ( <br /> FIRE ISTRICT INSPECTION DATE JARRIVALTIME DEPARTURE TIME 1INSPECTIONTYPE <br /> 11:91s- <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 7.Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate f <br /> 3.Bus ID Page/HMW 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 vj 113.Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"above must be explained in this section) <br /> REFERRALS ❑SJ Ag ❑ SJ Env 111th ❑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 Representative(Print Name and Title) BusinesRepresentative(Signa ore) <br /> N of I pe r nc Fire Co. (If Appr riate) W 1TECOPY: OPS REV 9/02 <br /> PINK COPY: BUSINESS <br />