Ecoserv, LLC.

• Client / Site

• Location
  Address

• PIC

• Conducted on

  Date

• Prepared by

• Location of Inspection
  Address

• List of personnel present during observation:

1.0 OFFICE WORK AREAS

• Is the required OSHA Job Safety and Health Protection Poster displayed in a prominent location visible to all employees <br>

  Yes

  No

  N/A

• Is the Summary of Work-Related Injuries and Illnesses (OSHA Form 300A) posted during the months of February, March and April<br>

  Yes

  No

  N/A

• Are office machines cords kept off floor to prevent tripping

  Yes

  No

  N/A

• Are desk and file cabinet drawers kept closed when not in use

  Yes

  No

  N/A

• Are emergency exits clearly marked and properly illuminate

  Yes

  No

  N/A

• Are emergency evacuation routes posted

  Yes

  No

  N/A

• Are emergency telephone numbers posted and readily available in case of an emergency

  Yes

  No

  N/A

• Are items such as lockers, file cabinets, bookcases and shelves secured

  Yes

  No

  N/A

• Are heavy objects stored on lower shelves

  Yes

  No

  N/A

• Are emergency lights operational

  Yes

  No

  N/A

• Are designated smoking areas clearly marked

  Yes

  No

  N/A

• Is the facility equipped with fire extinguisher or proper fire defense equipment and is it stored properly

  Yes

  No

  N/A

• Has the fire alarm system been inspected in the past (12) months

  Yes

  No

  N/A

• Are gutters and downspouts in place and secured

  Yes

  No

  N/A

• Are exterior lights operational

  Yes

  No

  N/A

• Area Photograph(s)

  Media

• Comments

2.0 FIRST-AID STATIONS

• Are first-aid kits available and adequately stocked

  Yes

  No

  N/A

• Is a first-aid log maintained for supplies issued

  Yes

  No

  N/A

• Are emergency eye wash stations available

  Yes

  No

  N/A

• Are portable emergency eyewash stations capped and easily accessible

  Yes

  No

  N/A

• Is a emergency shower available

  Yes

  No

  N/A

• Area Photograph(s)

  Media

• Comments

3.0 SAFETY MEETING

• Is a completed daily safety meeting form present

  Yes

  No

  N/A

• Does the form identify a task overview <br>

  Yes

  No

  N/A

• Are the topics adequate to the task and environment of work

  Yes

  No

  N/A

• Posting Photograph(s)

  Media

• Comments

4.0 (JSEA) JOB SAFETY ENVIRONMENTAL ANALYSIS/ PRE-JOB PLANNING

• Is a JSEA present for the task being performed

  Yes

  No

  N/A

• Is the JSEA signed by all personnel involved in the task including the PIC (Person in Charge)

  Yes

  No

  N/A

• Have all risks identified been properly mitigated

  Yes

  No

  N/A

• Has each mitigation been assigned to an individual or group

  Yes

  No

  N/A

• Have proper work permits been signed and acknowledged by all effecting parties

  Yes

  No

  N/A

• Is a rescue plan posted and in place

  Yes

  No

  N/A

• Posting Photograph(s)

  Media

• Comments

5.0 BEHAVIOR BASED SAFETY

• Is the S.H.I.N.E process being utilized

  Yes

  No

  N/A

• Are all personnel participating

  Yes

  No

  N/A

• Are the cards being properly completed (observed behavior, corrective action if applicable and/ or recommendations)

  Yes

  No

  N/A

• Is the PIC encouraging the process and reviewing observations daily

  Yes

  No

  N/A

• Photograph(s)

  Media

• Comments

6.0 SHORT SERVICE EMPLOYEE

• Has each SSE been assigned a mentor identified on the JSEA as well

  Yes

  No

  N/A

• Can each SSE identify their mentor

  Yes

  No

  N/A

• Do total number of SSE's exceed 20% of crew (1 to 5 ratio) shall not exceed unless a variance approved by the client

  Yes

  No

  N/A

• Photograph(s)

  Media

• Comments

7.0 WORK AREA FIRE PROTECTION

• Are an adequate number of fire extinguishers available

  Yes

  No

  N/A

• Are the extinguishers properly spaced, mounted at at compliant height and identified by signage

  Yes

  No

  N/A

• Are all the fire extinguishers inspected, charged and accessible

  Yes

  No

  N/A

• Are fire exits and extinguishers free of obstructions

  Yes

  No

  N/A

• Are cigarette containers specifically designed for cigarette butts

  Yes

  No

  N/A

• Is combustible and flammable material properly stored away from ignition sources

  Yes

  No

  N/A

• Are combustible and flammable storage areas clearly marked

  Yes

  No

  N/A

• Are emergency lights operational

  Yes

  No

  N/A

• Are emergency exits clearly marked and properly illuminate

  Yes

  No

  N/A

• Are emergency evacuation routes posted

  Yes

  No

  N/A

• Are emergency telephone numbers posted and readily available in case of an emergency

  Yes

  No

  N/A

• Area Photograph(s)

  Media

• Comments

8.0 FALL PROTECTION

• All practical options to eliminate the need to perform elevated work from heights have been explored

  Yes

  No

  N/A

• Fall protection risk and hazards have been identified on the task related JSEA

  Yes

  No

  N/A

• A rescue plan has been developed and all equipment needed to execute is readily available and on site

  Yes

  No

  N/A

• All fall arrest equipment/ systems being utilized are in good condition and have been inspected prior to use

  Yes

  No

  N/A

• Fall protection system(s) being utilized allow workers to tied off 100% of the time

  Yes

  No

  N/A

• Anchor point(s) are capable of supporting 5000lbs

  Yes

  No

  N/A

• Anchor point vertical of the user

  Safe

  At Risk

  N/A

• Photograph(s)

  Media

• Comments

9.0 OPEN HOLE: Openings 2" or greater located in any walking or working surface

• Open holes have been properly barricaded and/or covered

  Yes

  No

  N/A

• Barricades have a top rail and middle rail: top rails of each barricade are at least 42" in height and are capable of withstanding a load of at least 200lbs applied in any direction

  Yes

  No

  N/A

• A 4" kick plate, or third rail no more than 4" above the decking is installed if personnel are working below<br>

  Yes

  No

  N/A

• Open holes that cannot be immediately barricaded after exposure are monitored by an attendant (hole-watch) with no other duties and is equipped with fall protection at all times

  Yes

  No

  N/A

• Photograph(s)

  Media

• Comments

10.0 DROPPED OBJECTS

• Dropped objects risk and hazards have been identified on the task related JSEA

  Yes

  No

  N/A

• Suitable bins are provided for small, loose objects such as off-cuts, welding rod stubs, nuts and bolts, etc.

  Yes

  No

  N/A

• All hand tools are secure and restrained from free falling

  Yes

  No

  N/A

• The area below is adequately barricaded and personnel have visual warnings to increase awareness to anyone wanting to enter

  Yes

  No

  N/A

• The upper level work area is tidy and all loose material, pieces of scrap, unwanted tools and equipment are removed and positioned safely out of the way

  Yes

  No

  N/A

• Photograph(s)

  Media

• Comments

11.0 ELECTRICAL

• Are electrical enclosures such as switches, receptacles, junction boxes, etc., provided with tight-fitting covers or plates<br>

  Yes

  No

  N/A

• Are all disconnecting switches and circuit breakers labeled to indicate their use or equipment served<br>

  Yes

  No

  N/A

• Are all components free of missing or loose parts

  Yes

  No

  N/A

• Are all electrical cords in use clear of damage and in a serviceable condition

  Yes

  No

  N/A

• Do extension cords have a grounding conductor

  Yes

  No

  N/A

• Are there any extension cords through walls, doors, ceilings, under rugs or mats

  Yes

  No

  N/A

• Electrical panels marked to indicate servicing voltage

  Yes

  No

  N/A

• Are electrical tools marked with a sticker that reads- IGNITION SOURCE

  Yes

  No

  N/A

• Photograph(s)

  Media

• Comments

12.0 GRINDERS

• Do all grinders have the manufactures guards in place: control handle, disc guard and auto shut-off switch

  Yes

  No

  N/A

• Is double eye protection being utilized when grinding

  Yes

  No

  N/A

• Is the work rest and adjustable tongue on pedestal grinders properly set: 1/8" work rest and 1/4" tongue

  Yes

  No

  N/A

• Equipment Photograph(s)

  Media

• Comments

13.0 WELDING, CUTTING AND BRAZING

• Are "Metal Fume" respirators available to welders

  Yes

  No

  N/A

• Are cylinders legibly marked to clearly identify the contents or type of gas

  Yes

  No

  N/A

• Are compressed gas cylinders secure and safe for operation

  Yes

  No

  N/A

• Are cylinders, cylinder valves, couplings, regulators, hoses and apparatuses kept free of oily substances

  Yes

  No

  N/A

• Are cylinders properly stored at a minimum of 20' separation from combustible materials or by a non combustible barrier

  Yes

  No

  N/A

• Are "No Smoking" signs posted in the compressed gas cylinder storage area

  Yes

  No

  N/A

• Are compressed gas cylinders kept clear of ignition sources

  Yes

  No

  N/A

• Are fittings inspected for leaks and properly tightened (confirm with soap and water solution in spray bottle)

  Yes

  No

  N/A

• Are portable tinted barriers available in the welding/ cutting area

  Yes

  No

  N/A

• Are Arc Welding machines grounded

  Yes

  No

  N/A

• Photograph(s)

  Media

• Comments

14.0 CONFINED SPACE

• Has a rescue plan been developed, discussed, documented and posted prior to entry

  Yes

  No

  N/A

• Are confined spaces thoroughly emptied of any corrosive or hazardous substances, such as acids or caustics, before entry

  Yes

  No

  N/A

• Are all lines to a confined space that contain inert, toxic, flammable, or corrosive materials valved off and disconnected or isolated and separated before entry<br><br>* A flammable gas, vapor or mist in excess of 10% of its’ lower flammable limit (LFL)<br>* An oxygen deficient atmosphere containing less than 19.5% oxygen by volume or an oxygen enriched atmosphere containing more than 23.5% oxygen by volume<br>* Airborne combustible dust at a concentration that meets or exceeds its LFL (airborne combustible dust which obscures vision at five feet or less)<br> • An oxygen-deficient atmosphere has less than 19.5% available oxygen. Any atmosphere with less than 19.5% oxygen shall not be entered. This is an atmosphere that is Immediately Dangerous to Life and Health (IDLH) without an approved self-contained breathing apparatus (SCBA).<br><br>

  Yes

  No

  N/A

• Is either natural or mechanical ventilation provided prior to confined space entry<br>

  Yes

  No

  N/A

• Has the appropriate atmospheric tests been performed to check for oxygen deficiency, toxic substances and explosive concentrations in the confined space before entry

  Yes

  No

  N/A

• Is adequate illumination provided for the work to be performed in the confined space<br>

  Yes

  No

  N/A

• Is the atmosphere inside the confined space frequently tested or continuously monitored during work (should be posted)<br>

  Yes

  No

  N/A

• Is there a trained and equipped standby employee positioned outside the confined space, whose sole responsibility is to watch the work in progress, sound an alarm if necessary and render assistance<br>

  Yes

  No

  N/A

• Is the standby employee appropriately trained, comfortable and equipped to handle an emergency (can they explain their role and method of communication) <br>

  Yes

  No

  N/A

• Is approved respiratory equipment required if the atmosphere inside the confined space cannot be made acceptable <br>

  Yes

  No

  N/A

• Photograph(s)

  Media

• Comments

15.0 HIGH PRESSURE BLASTING

• Is the appropriate approved PPE being used during blasting and clean-up procedures

  Yes

  No

  N/A

• Is the operator(s) standing in a position that is safe and allows full control of the water jetting equipment without body strain

  Yes

  No

  N/A

• Is there a safety observer ready to shut down the system in the event of an emergency or a malfunction

  Yes

  No

  N/A

• Are the pressure jetting guns or lances equipped with a fast acting hold-to-activate device that when deactivated, will stop the flow of high pressure water (direct control of the operator)

  Yes

  No

  N/A

• Is the operator wearing personal protective clothing and equipment on their body, hands, arms, legs and feet, including the metatarsal area

  Yes

  No

  N/A

• Has all the equipment been inspected prior to beginning the process; i.e. guns, gauges, whip checks, hoses, etc.

  Yes

  No

  N/A

• Are fittings and valves properly secure

  Yes

  No

  N/A

• Are the hoses marked with the following information: manufacturers identification, date of manufacture and maximum operating pressure

  Yes

  No

  N/A

• Is the equipment being used including guns, foot control devices, hoses and nozzles suitable for use with greater than or equal to the maximum operating pressure of the high pressure pump

  Yes

  No

  N/A

• Is the jetting/ blasting system depressurized and secured when not in use and left unattended

  Yes

  No

  N/A

• The area is properly barricaded and also visual warnings signs have been posted to increase awareness of the hazards associated with entering the area

  Yes

  No

  N/A

• Is the cleaning procedure being performed in a well ventilated area

  Yes

  No

  N/A

• Are environmental practices being followed

  Yes

  No

  N/A

• Photograph(s)

  Media

• Comments

16.0 SCAFFOLDING

• Has the scaffolding been inspected and tagged approved for use

  Yes

  No

  N/A

• Is the scaffolding equipment equipped with the appropriate guard rails and work platforms

  Yes

  No

  N/A

• Is the staging surfaces level, smooth and free of obstructions (proper footing in place)

  Yes

  No

  N/A

• Equipment Photograph(s)

  Media

• Comments

17.0 LADDERS

• Are all ladders maintained in good condition, joints between steps and side rails tight, all hardware and fittings securely attached, and moveable parts operating freely without binding or undue play

  Yes

  No

  N/A

• Are non-slip safety feet provided on each metal or rung ladder, and are ladder rungs and steps free of grease and oil<br>

  Yes

  No

  N/A

• Are the labels readable and legible

  Yes

  No

  N/A

• Are portable metal ladders legibly marked with signs reading "CAUTION - Do Not Use Around Electrical Equipment" or equivalent wording<br>

  Yes

  No

  N/A

• Equipment Photograph(s)

  Media

• Comments

18.0 HOSES

• Are hoses in good, safe working condition

  Yes

  No

  N/A

• Are secondary protectors in place, i.e. safety pins and whip checks

  Yes

  No

  N/A

• Are the gaskets for each connection inspected and replaced if worn, distorted or too soft

  Yes

  No

  N/A

• Are hoses laid out so that they will not obstruct employees

  Yes

  No

  N/A

• Equipment Photograph(s)

  Media

• Comments

19.0 SLIP, TRIPS AND FALL HAZARDS

• Are drain covers and grates in good repair and properly installed

  Yes

  No

  N/A

• Are aisles and walkways properly marked and free of trip hazards such as cords or hoses<br>

  Yes

  No

  N/A

• Are walking surfaces free of oil or grease

  Yes

  No

  N/A

• Are standard guardrails provided wherever aisle or walkway surfaces are elevated more than 30 inches above any adjacent floor or the ground

  Yes

  No

  N/A

• Are stairway handrails capable of withstanding a load of 200 pounds, applied within 2 inches of the top edge in any downward or outward direction

  Yes

  No

  N/A

• Is there adequate lighting in all areas including exterior

  Yes

  No

  N/A

• Area Photograph(s)

  Media

• Comments

20.0 PERSONAL PROTECTION

• Type of Respiratory Protection Type of Eye Protection Type of Hand Protection Type Body Protection CFR 1910.134 ANSI Z87.1, CFR 1910.133. Proper to Task, CFR 1910.138 Proper to Element Exposure Type of Foot Protection Type of Head Protection Type of Fall Protection Type of Hearing Protection ASTM F2412-05, CFR 1910.136 ANSI Z89.1, CFR 1910.135 CFR 1910.269. CFR 1910.95

• Are all machine guards in place and properly set

  Yes

  No

  N/A

• Is proper PPE being utilized according to the JSEA

  Yes

  No

  N/A

• Is PPE being used appropriate for the task

  Yes

  No

  N/A

• Are the respirators National Institute for Occupational Safety and Health (NIOSH) approved for this particular application<br>

  Yes

  No

  N/A

• Are proper body mechanics being used

  Yes

  No

  N/A

• Equipment Photograph(s)

  Media

• Comments

21.0 NOISE

• Are there areas in the workplace where continuous noise levels exceed 85 decibels<br>

  Yes

  No

  N/A

• Are employees utilizing hearing protection

  Yes

  No

  N/A

• Comments

22.0 RIGHT TO KNOW

• Are SDS(s) present for all chemicals onsite

  Yes

  No

  N/A

• Are personnel aware of the location of the SDS(s)

  Yes

  No

  N/A

• Are personnel familiar with safety precautions regarding chemical usage

  Yes

  No

  N/A

• Is only the minimum amount of chemical in the area and/or properly contained

  Yes

  No

  N/A

• If chemicals are in use; were safe usage procedures included on the JSEA up to and including emergency procedures

  Yes

  No

  N/A

• Area Photograph(s)

  Media

• Comments

23.0 RIGGING

• Are all slings and rigging equipment inspected by a competent source every annually

  Yes

  No

  N/A

• Is all the rigging equipment equipped with legible identification tags

  Yes

  No

  N/A

• Are all the identification tags labeled with a working load limit

  Yes

  No

  N/A

• Is all rigging material inspected prior to use and the correct material for the task

  Yes

  No

  N/A

• Are all rigging hooks equipped with a working safety latch

  Yes

  No

  N/A

• Are proper rigging practices being followed

  Yes

  No

  N/A

• Are only qualified riggers performing rigging duties

  Yes

  No

  N/A

• Equipment Photograph(s)

  Media

• Comments

24.0 FORK-LIFT INDUSTRIAL TRUCKS

• Has a pre-use inspection been performed and is it documented; i.e. leaks (oil, air and water), appearance, signs and logos, safety equipment, lights, tires, etc.

  Yes

  No

  N/A

• Are employees properly trained in the use of the type of industrial truck they operate

  Yes

  No

  N/A

• Can the operator provide you with a documented pre-use inspection checklist

  Yes

  No

  N/A

• Is the operator utilizing a safety belt/ seatbelt when operating

  Yes

  No

  N/A

• Are industrial trucks that operate where flammable gases, vapors, combustible dust or ignitable fibers may be present approved for such locations<br><br>

  Yes

  No

  N/A

• Does each industrial truck have a warning horn, whistle or other device that can be clearly heard above normal noise in the areas where it is operated<br>

  Yes

  No

  N/A

• Are operators using ground guide personnel when maneuvering with in 10FT of any obstacle

  Yes

  No

  N/A

• Are loads handled only within the rated capacity of the truck<br>

  Yes

  No

  N/A

• Does the parking brake of the industrial truck prevent the vehicle from moving when unattended<br>

  Yes

  No

  N/A

• Equipment Photograph(s)

  Media

• Comments

25.0 HOUSEKEEPING

• Pictures of the area are a requirement of this section

• Area Photograph(s)

  Media

• Does the environment offers a designated area for food and drink consumption out of the work area

  Yes

  No

  N/A

• Are food or beverages consumed only in areas where there is no exposure to toxic material, blood, or other potentially infectious materials

  Yes

  No

  N/A

• Are waste receptacles emptied regularly

  Yes

  No

  N/A

• Are all water coolers sealed and labeled with a date of liquid fill

  Yes

  No

  N/A

• Comments

26.0 SPECIALITY OR CRITICAL TASK

27.0 WORK AREA SAFETY DRIVEN

• O to 5 you have observed behavior and/or questioned personnel and decided the work area is Production Driven. 6-10 is you have observed behavior and/or questioned personnel and decided the work area is Safety Driven

• Are pre-use inspections being performed on all company owned pieces of equipment

  Yes

  No

  N/A

• Are pre-use inspections documented; i.e. leaks (oil, air and water), appearance, signs and logos, safety equipment, lights, tires, etc.

  Yes

  No

  N/A

• Photograph(s)

  Media

• Comments

ONSITE CONVERSATION/ CONCERNS

• COMMENTS

SIGNATURES

• (PIC) Person In Charge Name

  Sign

• Name of Audit Facilitator

  Sign