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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> ROOM 610,COURTHOUSE <br /> = 222 EAST WEBER AVENUE <br /> STOCKTON, CALIFORNIA 95202 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> FAX(209)944-9015 <br /> HAZARDOUS MATERIALS PROGRAM INSPECTION FORM <br /> BUSINESS NAME TELEPHONE NUMBER <br /> L/ 40 <br /> BUSINESS ADDRESS (Facil ty eing Inspected) <br /> -7 Ave <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTION TYPE <br /> wait I-r-apj -r-7 1 4�1- a 10 1 c40 v� <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site AT Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 8.Chemical Inventory Complete and 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? 11.Hazardous Materials Being Properly Handled by Employee <br /> 5. Material Safety Data Sheets (MSDS) On Site 112.Hazardous Materials Properly Stored and Labeled <br /> 6. Current Training Records On Hand 113.Soil and Facility Appear Non-Contaminated <br /> COMMENTS (Items marked"NO"above must be explained in this section) <br /> r <br /> REFERRALS ❑ SJ Ag ❑ SJ Env Hlth ElOSHA ElFire ElDA ❑ <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 Repr entative(Print Name and Title) Business resentative Signature) <br /> Name of Inspector4rAgency Fire Co.(If Appropriate) WHITE COPY: OES <br /> L <br /> l"l PINK COPY: BUSINESS REV 9/02 <br />