Cha Brewery Lock Out Compliance Check

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date and Time of Compliance Check

  Date

Compliance Criteria

• Lock Out provided on:

  Machine itself

  At control panel

  At distribution board

• Lock Out Electrical or Mechanical:

  Electrical

  Mechanical

• Lock Out achieved by:

  Select Key switch Padlock Tongs/Calipers and Padlock Custom installed mechanical lock Pulling fuses Tagging only Tagging and locking Other means

  • Key switch
  • Padlock
  • Tongs/Calipers and Padlock
  • Custom installed mechanical lock
  • Pulling fuses
  • Tagging only
  • Tagging and locking
  • Other means

• If you selected Other means, please specify here ...

• Permit displayed/available

  Yes

  No

  N/A

• Permit signed by all relevant parties

  Yes

  No

  N/A

• Auditor Signature

  Sign

• Acceptor Signature

  Sign