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i COUNTY OF SAN JOAQUIN <br />OFFICE OF EMERGENCY SERVICES <br />m_tea, <br />s ROOM 610, COURTHOUSE <br />f 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 <br />lel o{9 <br />ITELEPHONE NUMBER <br />BUSINESS ADDRE (Facility Being Inspected) <br />, 3SS'0 Bozza, ,v ►Zoa-4 <br />FIRE DISTRICT <br />175- <br />INSPECTION DATE <br />ZI I 10S_ <br />ARRIVAL TIME <br />DEPARTURE TIME <br />I <br />INSPECTION TYPE <br />I 114AM / 4 <br />INSPECTION RESULTS <br />DOCUMENT REVIEW YES NO . FACILITY INSPECTION YES NO <br />1. Business HMMP/Inventory On Site <br />7. Facility Map Complete and Accurate <br />2. HMMP/Nlap Easily Accessible to Employees <br />8. 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 />/ <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 />V <br />1 <br />12. Hazardous Materials Properly Stored;and Labeled <br />6. Current Training Records On Hand <br />IZ <br />1 <br />13. Soil and Facility Appear Non -Contaminated <br />COMMENTS (Items marked "NO" above must be explained in this section) <br />REFERRALS ❑ SJ Ag ❑ SJ Env Hlth ❑ OSHA ❑ Fire ❑ DA ❑ <br />INSPECTION FOLLOW UP INFORMATION <br />Corrective Actions Muste Delivered to OES By <br />Follow Up Inspection Date <br />OES Inspector Name Performing Follow Up <br />ACKNOWLEDGEMENT OF REVIEW AND RECEIPT OF INSPECTION R SULTS <br />Business Representative (Print Name and itle) <br />Busin ss Representative (Signature) <br />Name of Inspe to'Agency Fire. Co. (If Appropriate) <br />sTL E 9,T <br />ITE COPY: OES <br />PINK COPY: BUSINESS <br />REV 9/02 <br />p - v <br />