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dh <br />1p <br />5. COUNTY OF SAN JOAQUIN <br />�' {I OFFICE OF EMERGENCY SERVICES <br />ROOM 610, COURTHOUSE <br />t 222 EAST WEBER AVENUE <br />.r STOCKTON, CALIFORNIA 95202 <br />HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />FAX (209) 944-9015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAMETELEPHONE <br />V/ Ic L i?i A <br />NUMBER <br />BUSINESS ADDRESS (Facility Being Inspected) <br />2V,104-6 q <br />FIRE/DISTRICT <br />Ir4PECTION DATE <br />ARRIVAL TIME <br />DEPARTURE TIME <br />INSPECTION TYPE <br />m_ <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO FACILITY INSPECTION <br />YES NO <br />1. Business HMMP/Inventory On Site <br />7. Facility Map Complete and Accurate <br />n <br />2. HMMP/Map Easily Accessible to Employee <br />'ZI) <br />8. Chemical Inventory Complete and Accurate <br />3. Bus ID Page/HMMP Complete and Accurate <br />71 <br />9. Employees Familiar with HMMP <br />4. If Business is a Hazardous Waste Generator, <br />are Hazardous Waste Manifests On Site? <br />10. Plant Operations Appear Safe <br />11. Hazardous Materials Being Properly Handled by Employees <br />5. Material Safety Data Sheets (MSDS) On Site <br />12. Hazardous Materials Properly Stored and Labeled <br />2r <br />6. Current Training Records On Hand <br />13. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />M <br />r ci <br />REFERRALS ❑ SJ Ag ❑ SJ Env Hlth ❑ OSHA ❑ Fire ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions Must be Delivered to OES By <br />Fo low Up Inspection Date <br />_15 -oil <br />OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION <br />RESULTS <br />Business Representative (Print Name and Title) <br />GM_ t <br />Name of Inspector Agency 'Fue Co. (If Appropriate) <br />WHIPE COPY: OES <br />PWKCOPY: BUSINESS <br />REV 9/02 <br />