BStorj Test

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Approval Status:

  Approved

  Disqualified

  Needs Review

• Company Representative:

• Ride Along Driver:

• Energi Safety Manager:

• Safety Manager:

• Phone Number:

• Clean Up Vendor:

• Phone Number:

• Summary (Exposures, Warranties, Company Overview):

• Doing a Gasoline/C-Store audit?

  Yes

  No

• Do the gasoline pumps areas contain proper signage? (i.e. no smoking, no cell phone use while pumping gas)?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Does the store have a video monitoring system?

  Yes

  No

  N/A

• What type?

• Please provide documentation.

  Media

• Are all nozzles equipped with a vapor recovery system and splash guards?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Are UST hatches color-coded so bulk drivers can identify which tank to deliver to?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Do employees do limited exchanging of money with the public?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Are emergency telephone numbers for law enforcement, fire, and medical services, and an internal contact person, posted at the phone?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Are interior and exterior lighting levels adequate?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Are curbs or steps visibly marked?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Are perishable foods within the expiration date?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• 10. Are aisles clear of product on the floor?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Are windows clear of advertising or other obstructions to allow for good visibility?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Is there a working drop safe or time access safe to minimize cash on hand?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Are there height markers on exit doors to help witnesses provide more complete descriptions of assailants?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• Are signs posted notifying the public that limited cash, no drugs, and no other valuables are kept on the premises?

  Yes

  No

  N/A

• Please provide documentation.

  Media

• General Notes:

By signing this document, you, as Energi's safety manager, are validating that all of the information is correct, to the best of your knowledge.

• Energi Safety Manager:

  Sign

By signing this document, you, as the Company Representative, are stating the information you have provided is correct, to the best of your knowledge.

• Company Representative:

  Sign