Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Location of Ammonia Plant

  • Are SDS Sheets Current?

Maximum Intended Inventory

  • Bulk Tanks

  • Size (Gallons)

  • Tank
  • Multiple Tanks?

  • Number of Tanks

  • Total Gallons: # of tanks X size =

  • Rail Car Transport Tanks

  • Size (Gallons)

  • Tank
  • Multiple Tanks?

  • Number of Tanks

  • Total Gallons: # of tanks X size =

  • Bulk Transport Trailers

  • Size (Gallons)

  • Tank
  • Multiple Tanks?

  • Number of Tanks

  • Total Gallons: # of tanks X size =

  • Nurse Tanks

  • Size (Gallons)

  • Tank
  • Multiple Tanks?

  • Number of Tanks

  • Total Gallons: # of tanks X size =

  • Total Quantity (Pounds): (Bulk Tanks + Rail Car Tanks + Bulk Transport Trailers + Nurse Tanks) X 4.6638=

Upper and Lower Perameters

Temperature (Degrees Fahrenheit)

  • Minimum Temperature (Degrees Fahrenheit)

  • Maximum Temperature (Degrees Fahrenheit)

Pressure(Pounds Per Square Inch Gauged)

  • Minimum Pressure (Pounds Per Square Inch Gauged)

  • Maximum Pressure (Pounds Per Square Inch Gauged)

Flow (Gallons Per Minute)

  • Minimum Flow (Gallons Per Minute)

  • Maximum Flow (Gallons Per Minute)

Composition (% Anhydrous Ammonia)

  • Minimum Composition (% Anhydrous Ammonia)

  • Maximum Composition (% Anhydrous Ammonia)

Codes and Standards

  • CGA 2.1 Standards used to design, build, and operate?

  • Are generally accepted and good engineering practices followed?

  • Has their been major changes in the safety information to make it inaccurate?

  • Changes in Information

  • Change

Storage Tank Information

  • Storage Tank Data Plate

  • Tank
  • Location of Storage Tank?

  • Vessel/Tank I.D.

  • Manufacturer

  • Serial #

  • Manufacture Date

  • ASME Code

  • Board Registration #

  • Above Ground/Underground

  • Min/Max Design Temperatures (Degrees Fahrenheit)

  • Wall Thickness Shell/Head (inch, mm)

  • Water Capacity (lb, kg, gal, m^3)

  • Outside Surface Area (ft^2' m^2)

  • Is the data plate present and legible?

Compressor/Pump Information

  • VaporCompressor ID

  • Compressor
  • Location of Vapor Compressor?

  • Manufacturer/Model/Serial #

  • CFM/GPM Pressure (inlet/outlet)

  • Motor Info: Manufacturer/Model/Serial #

  • Motor Info: HP/RPM/Amps

  • Manufacturer's Safe Operation, Maintenance, and Technical Information on Hand?

  • Liquid Pump ID

  • Liquid Pump
  • Location of Liquid Pump?

  • Manufacturer/Model/Serial #

  • CFM/GPM Pressure (inlet/outlet)

  • Motor Info: Manufacturer/Model/Serial #

  • Motor Info: HP/RPM/Amps

  • Manufacturer's Safe Operation, Maintenance, and Technical Information on Hand.

Storage Tank Appurtenances

    Pressure Relief Valve
  • Location of Pressure Relief Valve?

  • Set Pressure (psig)

  • Rate of Flow (CFM)

  • Manufacture Date

  • Date Replaced

  • Manufacturer, Serial #

  • Hydrostatic Valves

  • Hydrostatic Valve
  • Location of Hydrostatic Valve?

  • Set Pressure (psig)

  • Rate of Flow (CFM)

  • Manufacture Date

  • Date Replaced

  • Manufacturer, Serial #

  • Belly Valves

  • Belly Valve
  • Location of Belly Valve?

  • Manufacturer

  • Model #

  • Liquid or Vapor

  • Pressure Relief Valve Manifold

  • PRV Manifold
  • Location of Pressure Relief Manifold?

  • Location

  • Manufacturer

  • Model #

  • Emergency Shutoff Valve

  • Shutoff Valve
  • Location of Emergency Shutoff Valve?

  • Manufacturer

  • Model #

  • Liquid or Vapor

  • Percent Fill Gauge

  • Gauge
  • Location of Percent Fill Gauge?

  • Manufacturer

  • Model #

  • Approved for anhydrous?

  • Pressure Gauge

  • Gauge
  • Location of Pressure Gauge?

  • Manufacturer

  • Model #

  • Approved for Anhydrous?

Riser Appurtenances

  • Pressure Relief Valves

  • Pressure Relief Valve
  • Location of Pressure Relief Valve?

  • Set Pressure (psig)

  • Rate of Flow (CFM)

  • Manufacture Date

  • Date Replaced

  • Manufacturer, Serial #

  • Hydrostatic Valves

  • Hydrostatic Valve
  • Location of Hydrostatic Valve?

  • Set Pressure (psig)

  • Rate of Flow (CFM)

  • Manufacture Date

  • Date Replaced

  • Manufacturer, Serial #

  • Liquid Globe Valve
  • Location of Liquid Globe Valve?

  • Manufacturer

  • Model #

  • Valve Size

  • Vapor Globe Valve
  • Location of Vapor Globe Valve?

  • Manufacturer

  • Model #

  • Valve Size

  • Liquid Angle Valve
  • Location of Liquid Angle Valve?

  • Manufacturer

  • Model #

  • Valve Size

  • Vapor Angle Valve
  • Location of Vapor Angle Valve?

  • Manufacturer

  • Model #

  • Valve Size

  • Pull-Away Protection

  • Pull-Away Protection
  • Location of Pull-Away Protection?

  • Manufacturer

  • Model #

  • Size

  • Hose I.D.

  • Hose
  • Location of Hose?

  • Manufacturer

  • Working Pressure

  • Manufacture Date

  • Replace By Date

  • Riser Emergency Shutoff Valves

  • ESV
  • Location of Emergency Shutoff?

  • Manufacturer

  • Serial Number

  • Liquid or Vapor?

Bulk Head Appurtenances

  • Hydrostatic Valves

  • Hydrostatic Valve
  • Location of Hydrostatic Valve?

  • Set Pressure (psig)

  • Rate of Flow (CFM)

  • Manufacture Date

  • Date Replaced

  • Manufacturer, Serial #

  • Back Check Valve
  • Location of Back Check Valve?

  • Manufacturer

  • Model #

  • Valve Size

  • Liquid Globe Valve
  • Location of Liquid Globe Valve?

  • Manufacturer

  • Model #

  • Valve Size

  • Vapor Globe Valve
  • Location of Vapor Globe Valve?

  • Manufacturer

  • Model #

  • Valve Size

Bulk Head Emergency Shutoff

  • Emergency Shutoff Valve

  • Emergency Shutoff
  • Location of Emergency Shutoff Valve?

  • Manufacturer

  • Model #

  • Liquid or Vapor

  • Excess Flow Valve
  • Location of EFV.

  • Valve I.D.

  • Max Allowed Flow (GPM)

  • Manufacturer

  • Model #

  • Management Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.