Anonymous

Diesel Permit Information

Underground Equipment

Use this Template

Print as PDF

Use this Template

Go digital today!

Convert your paper checklists into digital forms

Scan this QR code to use this paper checklist on your smartphone or tablet or visit https://safetyculture.com/

Title Page

Company
Conducted on
Mine
Area of operation
Type of equipment
Purpose
Manufacturer
Serial number of Equipment
Max operating grade
Max authorized load
Unit Identification Date
Equipment model
Company unit number
Unit conforms with CSA standards
Canmet certification number
MSHA certification number
Engine make
Engine model
Engine serial number
Maximum rated load
Maximum RPM
Maximum fuel injection rate (lb/hr)
After treatment type
After treatment manufacturer
After treatment model
Fuel type
Fuel capacity
Capacity of tanks
Hydraulic Fluid type
Fire suppression type
Fire suppression number of nozzles
Fire suppression size
Fire extinguisher type and size
Ventilation required
Service braking system
Emergency brake
Parking brake
Unit height Feet
Unit width Feet
Unit length Feet
AME representative
AME representative signature
Client representative
Client representative signature

Anonymous

Diesel Permit Information

Underground Equipment

Use this Template

Print as PDF

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.