Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Company Personnel on. Board
Job Setup
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Barricade
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House keeping
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Pump Manned
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Line of Sight
Personal Safety
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Head
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Eye & Face
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Hearing
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Hand
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Clothing
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Fall Protection
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Respirator
Ergonomics
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Straining
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Over-extending
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Lifting (back)
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Line of Fire
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Body Positioning
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Safe Footing
Safety/Compliance
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Per-job Checklist
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Permits
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MSDS
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Pre/Post Trip
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Lockout Tagout
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Confined Space
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Variance
Equipment
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Use
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Fittings
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Ground
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No Leaks
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Chocks
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Relief Valves
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Guards
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Hoses
Hazard Control
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H2O Cuts
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Trips/Slips
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Chemical Exposure
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Pinch Points
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Spills
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Heat Stress
Vehicle Use
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Speed
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Space Cushion
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Land Guide
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Seat Belts
Shotgunning
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66" Total
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6' Shroud
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Whip Check
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Guard Trigger
Chemical Cleaning
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Job Plan
Air Machine
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Safety "T"
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Handle in Place
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Flash Point Below 140
Liquid Vacuum
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Cam Locks
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Not Over Filled
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Handling Hose PPE
Lance or Line Mole
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Safe Hands
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No Gap @ Tubesheet
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Channel Head
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Stabbed Controls
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Stinger 1 1/2 X Pipe Diameter
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Hose Marked 3'
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Guard on Back
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Foot Pedal
Tank Cleaning
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Cam Locks
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Hazard Signs
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Sump Barricade
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Temp Gauge
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Hose Connections
COMMENTS
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Additional Hazards Identified
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Overall Evaluation of Job