JSO

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Job Setup

• Barricade

  Yes

  No

  N/A

• House keeping

  Yes

  No

  N/A

• Pump Manned

  Yes

  No

  N/A

• Line of Sight

  Yes

  No

  N/A

Personal Safety

• Head

  Yes

  No

  N/A

• Eye & Face

  Yes

  No

  N/A

• Hearing

  Yes

  No

  N/A

• Hand

  Yes

  No

  N/A

• Clothing

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

• Respirator

  Yes

  No

  N/A

Ergonomics

• Straining

  Yes

  No

  N/A

• Over-extending

  Yes

  No

  N/A

• Lifting (back)

  Yes

  No

  N/A

• Line of Fire

  Yes

  No

  N/A

• Body Positioning

  Yes

  No

  N/A

• Safe Footing

  Yes

  No

  N/A

Safety/Compliance

• Per-job Checklist

  Yes

  No

  N/A

• Permits

  Yes

  No

  N/A

• MSDS

  Yes

  No

  N/A

• Pre/Post Trip

  Yes

  No

  N/A

• Lockout Tagout

  Yes

  No

  N/A

• Confined Space

  Yes

  No

  N/A

• Variance

  Yes

  No

  N/A

Equipment

• Use

  Yes

  No

  N/A

• Fittings

  Yes

  No

  N/A

• Ground

  Yes

  No

  N/A

• No Leaks

  Yes

  No

  N/A

• Chocks

  Yes

  No

  N/A

• Relief Valves

  Yes

  No

  N/A

• Guards

  Yes

  No

  N/A

• Hoses

  Yes

  No

  N/A

Hazard Control

• H2O Cuts

  Yes

  No

  N/A

• Trips/Slips

  Yes

  No

  N/A

• Chemical Exposure

  Yes

  No

  N/A

• Pinch Points

  Yes

  No

  N/A

• Spills

  Yes

  No

  N/A

• Heat Stress

  Yes

  No

  N/A

Vehicle Use

• Speed

  Yes

  No

  N/A

• Space Cushion

  Yes

  No

  N/A

• Land Guide

  Yes

  No

  N/A

• Seat Belts

  Yes

  No

  N/A

Shotgunning

• 66" Total

  Yes

  No

  N/A

• 6' Shroud

  Yes

  No

  N/A

• Whip Check

  Yes

  No

  N/A

• Guard Trigger

  Yes

  No

  N/A

Chemical Cleaning

• Job Plan

  Yes

  No

  N/A

Air Machine

• Safety "T"

  Yes

  No

  N/A

• Handle in Place

  Yes

  No

  N/A

• Flash Point Below 140

  Yes

  No

  N/A

Roll-off Truck

• Box Secure

  Yes

  No

  N/A

• Tarp

  Yes

  No

  N/A

• Labels

  Yes

  No

  N/A

• Bill of Lading

  Yes

  No

  N/A

Liquid Vacuum

• Cam Locks

  Yes

  No

  N/A

• Not Over Filled

  Yes

  No

  N/A

• Handling Hose PPE

  Yes

  No

  N/A

Lance or Line Mole

• Safe Hands

  Yes

  No

  N/A

• No Gap @ Tubesheet

  Yes

  No

  N/A

• Channel Head

  Yes

  No

  N/A

• Stabbed Controls

  Yes

  No

  N/A

• Stinger 1 1/2 X Pipe Diameter

  Yes

  No

  N/A

• Hose Marked 3'

  Yes

  No

  N/A

• Guard on Back

  Yes

  No

  N/A

• Foot Pedal

  Yes

  No

  N/A

Tank Cleaning

• Cam Locks

  Yes

  No

  N/A

• Hazard Signs

  Yes

  No

  N/A

• Sump Barricade

  Yes

  No

  N/A

• Temp Gauge

  Yes

  No

  N/A

• Hose Connections

  Yes

  No

  N/A

COMMENTS

• Additional Hazards Identified

  Yes

  No

  N/A

• Overall Evaluation of Job

  Yes

  No

  N/A