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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> 222 EAST WEBER AVENUE <br /> j STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> PAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> 2-2. 4 (0 _Z�r_ 0 , 4- V-. <br /> FIRE DISTRICT INSPECTION DATE JARRIVAL TIME DEPARTURE TIME INSPECTIO TYPE <br /> G n i/p�SOfo !L 2 S i /Cs.+ `/ cL <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site vj 7.Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and Accurate <br /> 3.Bus ID PagcaMMP 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? Al./Ar I1.Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets (MSDS)On Site 12.Hazardous Materials Properly Stared and Labeled <br /> 6.Current Training Records On Hand 13.Soil and Facility Appear Non-Contaminated ✓ <br /> C <br /> O <br /> MMENTS (Items marked"NO"above must be explained in this section) J <br /> X � /l-e-- P tvi s�. � d /G� -<! Pc�� � c c. / iLt ✓R Y T+•' <br /> TOOl3- G l c •'f t a d ���t�, <br /> . ed >� l it �_ <br /> REFERRALS ❑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 /> w•L-Q-- (P Z.CO <br /> ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RF,$ULTS <br /> Business Representative(Print Name anTitle) Bus i Rep septa ' e(Signature) <br /> TWA- /-� <br /> Na.me,of Inspecto Agency Fir o.(If Appropriate) WHITE COPY: OES <br /> 10�1 PINK COPY: BUSINESS REV 9/02 <br />