Title Page
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Facility Name
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Prepared by
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Conducted on
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Facility Type
- Water Pump Station
- Sewer Lift Station
- Vault
- Meter Pit
- Water Treatment Plant
- Sewer Treatment Plant
- Chemical Building/Chemical offloading
- Power Generation
- Power Distrtibution
Facility Inspection
General Work Area/Conditions
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Site orientation materials for visitors are available and current
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Areas where people will walk or work are free of weeds/debris
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Ladders/Guardrails/Handrails in good condition
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Access/Egress points clear of obstruction
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All walking-working surfaces such as stairs, aisles, and walkways free of obstructions or slip, trip, fall hazards
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Exterior of facility generally clean and orderly
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Interior of facility generally clean and orderly
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Areas where people will walk or work are adequately illuminated to safely operate after dark
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All floor holes, ladder access and wall openings are guarded or barricaded to prevent a fall
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Safety equipment such as, safety showers, eyelashes, emergency stops, fire alarm, fire extinguishers, and medical supplies are unobstructed
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Waste receptacles clean, adequately segregated, and not overflowing
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General housekeeping is overall good condition
Emergency Response/First Aid
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First Aid kit on-site and stocked
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Shower/Eyewash stations accessible and inspected monthly
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Emergency evacuation routes posted
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Exits clearly marked
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AEDs operational and inspected monthly
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Emergency Response Plan (ERP) on-site with up-to-date information
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Emergency Response Plan (ERP) is uploaded into MapCall and current
Security
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Visitor access control in place (sign-in, site briefing, who’s on site)
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Perimeter of site barricaded or otherwise protected
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Fencing/Gates in acceptable condition
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No Tespassing signs posted on outside of structure
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All doors, hatches, opening, etc. properly secured
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Facility/Equipment monitored via SCADA
Fire Safety
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Fire alarm system certified and tested annually
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Sprinkler systems are not obstructed and are maintained and inspected
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Flammable materials stored in flammable storage cabinet
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Flammable storage cabinets properly maintained
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No combustible or flammable materials stored near electrical breakers
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Stockpiling of combustible materials prevented
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Fire extinguishers accessible and appropriate class for present hazards
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Fire extinguisher locations visibly marked and unobstructed
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Monthly fire extinguisher inspections documented
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Designated Hot Work areas are labeled and free of combustibles and flammables
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Demonstrated consistent use of Hot Work permit in MapCall and adherence to process
Personal Protective Equipment
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Signs with required PPE posted
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Supply of required PPE stocked
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PPE stored properly
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PPE cleaning supplies available where shared PPE is used
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Documentation of PPE inspections available for high voltage gloves, body harnesses, and non-disposable respirators
Chemical Storage/HAZCOM
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Chemicals/materials properly stored and maintained
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Chemical containers labeled legibly
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SDSs accessible and up-to-date
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Appropriate chemical hazard warning signs posted
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Emergency spill/repair kits readily accessible and equipped for the appropriate volume
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Area clean and free of chemical spills
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Incompatible materials stored separately
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Chemical containers closed and secured when not in use
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Chemical containers in good conditions and free of leaks
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Compressed gas cylinders secured and stored properly
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Secondary containment in good condition
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Chemical waste is labeled and dated, segregated, inspected, and disposed of in accordance with state regulations
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Proper documentation of disposed material
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Chemical fill lines locked when not in use
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Confirmation that chemicals are received in accordance with practice
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Alarm asset records (Cl2, O3, O2, etc.) reviewed in MapCall with demonstrated adhereance to PM schedule and are in proper working order
Equipment/Tools
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Hand tools in good condition
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Equipment and tools are free from dirt, visible leaves, and working properly
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No broken, damaged, or worn tools present
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Electrical cabinets/equipment in good condition and labeled
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Extension cords of the proper type and size used and in good condition
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Extension cords are elevated where possible
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Extension cords are not run through ceilings, walls, or doorways
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Extension cords which cross walkways are securred
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Extension cords which cross vehicle paths are shielded
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GFCI adapters, pigtails or power strips are in use where GFCI circuit breakers are not installed
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Voltage posted on electrical components
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Live electrical components properly guarded
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All moving/rotating parts properly guarded and any manufacturer guards remain in place
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Equipment/machinery securely placed/anchored
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Manufacturer’s manuals available on-site for powered equipment
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ARC flash labeling in place an current
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Equipment stored further than 3-ft from electrical panels
Confined Space
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All permit-required confined spaces physically labled and identified on the site inventory list
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All confined space air monitoring equipment is inventoried in MapCall and calibration is up to date
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Exhaust fans functioning properly
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Access to all permit required confined spaces are guarded
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Emergency retrieval equipment in good condition
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Rescue services identified
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Demonstrated consistent use of confined space form in MapCall and adherence to process
Vehicle/Motorized Equipment
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Vehicles clean and well organized
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Annual DOT inspection current
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Daily inspections completed and recorded
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All safety features functioning (backup alarms, lights, brakes, etc.)
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Appropriate traffic control equipment available
OSHA Training
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Employee on-site were current with all required OSHA training (cross-check with LEARN)
