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Alk <br /> ' Au1N <br /> COUNTY OF SAN JOAQUIN <br /> xa � OFFICE OF EMERGENCY SERVICES <br /> ROOM 610, COURTHOUSE <br /> m, ` 222 EAST WEBER AVENUE <br /> �'• STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3969 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSWESS NAME TELEPHONE NUMBER <br /> BUSINESS ADDUSS(Facility being Inspected) 21PCODE <br /> FIRE DISTRI INSPECIION DATE ARRIVAL TIME DEPARTURE TIME INSPECI70N E <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY WALK THROUGH YES NO <br /> 1. Business HMMP/Inventory On Site x 7. Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees x 8. Chemical Inventory Complete&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 X 11.Materials Being Properly Handled <br /> 5.Material Safety Data Sheets (MSDS)On Site 12.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 /> 21 O <br /> REFERRALS (FOR OES USE ONLY) ❑SJ Ag ❑SJ Env Hlth [—]OSHA ❑ Fire [:]Air Dist <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 INSPECTIOWNRESULTS <br /> Business Representative(Print Name and Title) Bus' a ese tiv Si ore) <br /> Name of Inspector an ire CompanyWHITE Y: 0131 <br /> / CAN COPY: FIRE PREVENTION REV 11196 <br /> O d a / C.p PINK COPY: BUSINESS <br /> OES HM1(11M) <br />