Circle S Inc.

• Location
  Address

• Supervisor/Crew Leader

• Job description

• Conducted on

  Date

• Prepared by

• Personnel

Work order

• JHA and Tool Box Safety meeting filled out correctly and all employees signed

  Yes

  No

  N/A

• All permits filled out correctly with customer Rep Signature and Circle S rep Signature in proper place

  Yes

  No

  N/A

• Crew is aware of all hazards and how to avoid them

  Yes

  No

  N/A

• Pre job inspection done on equipment/vehicles

  Yes

  No

  N/A

Safety controls

• LOTO done correctly

  Yes

  No

  N/A

• MSDS SHEETS CORRECT IF APPLICABLE

  Yes

  No

  N/A

• Is Job in Confined space

  Yes

  No

  N/A

• Has confined space air quality been tested?

  Yes

  No

  N/A

• Has monitor been bump tested with in 24 hours and in calibration?

  Yes

  No

  N/A

• All PPE present and properly used (Hard hat, safety glasses, ear plugs, steel toe boots (Lace Up where required)

  Safe

  At Risk

  N/A

• Are ladders, scaffold, fall protection needed in use

  Yes

  No

  N/A

• Are the ladders, scaffolds, and man lifts being used properly

  Safe

  At Risk

  N/A

• fall protection equipment in use in good condition and being used properly

  Safe

  At Risk

  N/A

• Is Fall Protection being used

  Safe

  At Risk

  N/A

Confined Space

• Is Confined Space permitted by customer

  Yes

  No

  N/A

• Verify Confined Space is in lock out procedure

  Yes

  No

  N/A

• Is a 4 gas monitor being used

  Yes

  No

  N/A

• Has monitor been calibrated in previous 12 months

  Yes

  No

  N/A

• Has monitor been bump tested within 24 hours and documentation on job site or (Job trailer)

  Yes

  No

  N/A

• Is Safety rope being used if only one person in confined space or if multiple entrants a safety rope at the entry point as needed for rescue

  Yes

  No

  N/A

• Confined space attendant present

  Yes

  No

  N/A

• Has Confined space attendant been trained and fully aware of his duties and expectations (emergency procedures)

  Yes

  No

  N/A

• Does confined space attendant have high vis vest and Radio and or Emg numb

  Yes

  No

  N/A

• Does Attendant understand the use and functions of the monitor being used

  Yes

  No

  N/A

• Are safety harnesses being used in the confined space

  Yes

  No

  N/A

• Confined Space Entrants been trained in confined space job task and PPE

  Yes

  No

  N/A

• Attendant Log sheet being used and kept current with entrants in the confined space

  Yes

  No

  N/A

Hydroblasting General Safe Work Practices

• 4.2.2 house keeping-Is the work area free of all removable hazards?

  Yes

  No

  N/A

• 4.2.4 Is pump properly barricaded to restrict unauthorized people from entering the work area.

  Yes

  No

  N/A

• 4.2.4 is area being cleaned properly barricaded to prevent unauthorized people from entering and using Signs

  Yes

  No

  N/A

• 4.2.4 is pre-printed barricade tags properly attached (Danger hydroblasting)

  Yes

  No

  N/A

• 4.2.5 Are wheel chocks in place on pump and truck

  Yes

  No

  N/A

• 4.2.6. Whip checks in place and tight on all hoses

  Yes

  No

  N/A

• 4.2.7 Is pump operator present and close enough to disengage pressure

  Yes

  No

  N/A

• 4.2.8 Is there clear line of site between pump operator and hose end equipment operator. If unable to do so is radio or third person in use

  Yes

  No

  N/A

• 4.2.9 Are hoses routed and protected in a manner that prevents vehicular damage and personnel exposure to hoses

  Yes

  No

  N/A

• 4.2.10 Are all personnel 6' or more away from hose connections while under pressure

  Yes

  No

  N/A

• 4.2.12 Are debris barriers in place

  Yes

  No

  N/A

• 4.2.15 Is a hard stop required. If so is it being utilized

  Yes

  No

  N/A

• 4.2.17 Is hose shroud in place

  Yes

  No

  N/A

• 4.2.18 Has back thrust been calibrated to 1/3 of operator and properly applied

  Yes

  No

  N/A

• 4.2.19 Is operator controlling the foot pedal

  Yes

  No

  N/A

• 4.2.20 Is foot pedal secure and free from obstruction

  Yes

  No

  N/A

• 4.2.21 If people working below is the water from foot pedal being redirected by using 3/4 hoses coming off foot pedal

  Yes

  No

  N/A

Hydroblasting Equipment Requirements

• 4.3.4 is stinger at least 1.5x the diameter of pipe being cleaned

  Yes

  No

  N/A

• 4.2.5 Is lance marked 24"or more from the end of the compression fitting

  Yes

  No

  N/A

• 4.3.6 Does shotgun have hose shroud

  Yes

  No

  N/A

• 4.3.6 Is the shotgun shroud 6' in length

  Yes

  No

  N/A

• 4.3.6 Has shotgun shroud been properly inspected for current qtr

  Yes

  No

  N/A

• 4.3.7 Is the length of the shotgun 66" from butt stock to end of the nozzle

  Yes

  No

  N/A

• 4.3.8 Are fittings rated for pressure being applied?

  Yes

  No

  N/A

• 4.3.9 Does shotgun have a double trigger lock

  Yes

  No

  N/A

• 4.3.10 Is entry point where 3D tool is in operation securely covered to prevent spray from exiting vessel

  Yes

  No

  N/A

• 4.3.10 Is 3D tool appropriately suspended (rope not allowed)

  Yes

  No

  N/A

• Blast hose inspected with metal tag in place

  Yes

  No

  N/A

• Blast hose in good repair

  Yes

  No

  N/A

• Hydro Blast unit level and wheels chocked

  Yes

  No

  N/A

• 10k

• 20k

• 40k

Vacuuming

• Has Vacuum check list been preformed and present on Job Site

  Yes

  No

  N/A

• If necessary, is vac truck properly bonded and ground meter being used and verified continuity

  Yes

  No

  N/A

• Is job on an elevated floor

  Yes

  No

  N/A

• Is vac hose properly tied off

  Yes

  No

  N/A

• Is product being vacuumed combustible dust

  Yes

  No

  N/A

• Is conductive hose being used

  Safe

  At Risk

  N/A

• Is there a hose break in use and in close proximity of the work being preformed

  Yes

  No

  N/A

Vehicle/equipment

• Is fire extinguisher in place and inspected

  Yes

  No

  N/A

• Is vehicle/equipment clean

  Yes

  No

  N/A

• Does vehicle have current Inspection sticker, Tag, and current insurance card

  Yes

  No

  N/A

• Does vehicle have clear company logo's on side in good condition

  Yes

  No

  N/A

Employee Appearance and Professionalism

• Does employees have on Uniforms

  Yes

  No

  N/A

• Is the shirts of the uniforms tucked in with belt on

  Yes

  No

  N/A

• Are Employee's clean shaving to comply with company policy

  Yes

  No

  N/A

Observations

Corrective Action

• Auditor

  Sign

• Crew Leader/Supervisor

  Sign