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i <br />COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />ROOM 610, COURTHOUSE <br />*� 222 EAST WEBER AVENUE <br />J STOCKTON, CALIFORNIA 95202 <br />• , L$ i + HAZARDOUS MATERIALS DIVISION (209) 468-3969 <br />FAX (209) 944-9015 <br />HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br />BUSINESS NAME <br />+ L C1 <br />TELEPHONE NUMBER <br />2U9 7 7—S" 77 <br />ed) <br />BUSINESS ADDRESS // acility eing In DCL!/ <br />930 Jr. Char ey- .J �c�K�Qva L,l`LD ry <br />FIRE DISTRICT/ <br />. a /c <br />INSPECTION A E <br />9/Z 7/0 4 <br />ARRIVAL TIME <br />1 D 9 3 0 <br />DEPARTURE TIME <br />INSPECTION TYPE <br />INSPECTION RESULTS <br />DOCUMENT REVIEV� YES NO FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />17, Facility Map Complete and Accurate <br />2. HMMP/Map Easily Accessible to Employees <br />18. Chemical Inventory Complete and Accurate <br />3. Bus ID Page/HMMP Complete and Accurate <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 Employee <br />5. Material Safety Data Sheets (MSDS) On Site <br />12. Hazardous Materials Properly Stored and Labeled <br />6. Current Training Records On Hand <br />1 <br />113. Soil and Facility Appear Non -Contaminated <br />.NO" above must be exp ained in this section) <br />COMMENTS (Items mro'n <br />x SS c ✓vc l� ca C- Q 0 <br />s c r/o.. of ry 4-- 9 O ".0 2 C4 0-i 7 i ,. Vo -, it ) <br />a <br />�.ck- <br />.+� 04 ..' a I v ^ S-/ vl 7P <br />20 <br />REFERRALS ❑ SJ Ag ❑ SJ Env Hlth ❑ OSHA ❑ Fire [IDA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions Must be Delivered to OES By <br />Follow Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION RESULTS <br />Business Representative (Print Name and Title) <br />Iq <br />Business Represe�ativee((Signature) <br />N of I Ispec r A ' y r Fire Co. (ff A r94riate) <br />g,r0 A_:0 ZAT �J <br />rWHITT1 COPY: OES <br />PINKCOPY: BUSINESS <br />I REV 9102 <br />I <br />