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COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> .41 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 /> �1 <br /> BUSINESS ADDRESS(Facility Being Inspected) <br /> AC <br /> FIRE DISTRICT INSPECTION DATE ARRIVAL TIME DEPARTURE TIME INSPECTIO TYPE <br /> ( 3-2-dLLHP <br /> INSPECTION RESULTS <br /> DOCUMENT REVIEW YES NO FACILITY INSPECTION YES NO <br /> 1. Business HMMP/Inventory On Site 17.Facility Map Complete and Accurate <br /> 2. HMMP/Map Easily Accessible to Employees 18.Chemical Inventory Complete and Accurate <br /> 3.Bus ID Page/HMMP Complete and Accurate 19. 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 /> STATE LICENSE <br /> No.421833 <br /> •STRIPING <br /> T affic Limited •MARKERS <br /> •STUDIES <br /> •SIGNS <br /> MITCHELL S.KAY (-e4 (916) Z)`7- 12-43 <br /> P. O. BOX 1721 TELEPHONE <br /> LODI,CA 95241-1721 (209)334-5172 <br /> F44-A X09 ) 33y- 0706 <br /> REFERRALS ❑SJ Ag ❑SJ Env Hlth ❑OSHA ❑Fire ❑DA ❑ <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 Representative(Print Name and Title) B iness Represe tative ignature) <br /> ��1 ► c{�C) <br /> Name f Ir Agency Fire Co (I A ropriate TE COPY: OES <br /> '` PINK COPY: BUSINESS E9/il <br />