HFA Maintenance Request

• Title of Worksite Inspection (if required)

• Operator name

• Team Leader

• Date and time

  Date

Maintenance request details

• Place of work

  Select Hulling Room Protein and Flour Room General Area

  • Hulling Room
  • Protein and Flour Room
  • General Area

• Other place of work

• Equipment type

• Description of maintenance requirements and action taken

  Minor continue use

  Major work stopped

  Major equipment stopped

• Additional observations

• Photo

  Media

• Verified (Name and signature)

  Sign

Maintenance completed details (If required)

• Description of work completed

  Repaired

  Minor repair

  Tagged out

  Major repair

• Additional comments and recommendations

• Name and signature of person completing maintenance request

  Sign