Title Page
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Conducted on
Information Items
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Enter Equipment Name:
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Take Picture of Piece of Equipment
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Attach Location Address
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Copy GPS Coordinates:
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Scope of Work Requiring LOTO:
Energy Sources
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Electricity - Main Power
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Amps:
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Volts:
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# of Phase:
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Electricity - Control Circuit(s)
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Amps:
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Volts:
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# of Phase:
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Electricity - Battery / Solar / Alternative Power (AC/DC/PH)
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Amps:
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Volts:
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# of Phase:
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Compressed Air / Gases
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PSI:
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Gas Type:
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Steam / Condensate
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PSI:
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Source:
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Fluid Under Pressure
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PSI:
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Source:
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Thermal - Heat or Cold
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Temperature in Degrees Fahrenheit:
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Source:
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Vacuum Chamber / Piping
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Height in Inches:
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Source:
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Fuel(s) - Solid / Liquid / Gas
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Volume:
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Fuel:
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Rotating Wheel / Fan / Drive
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Details:
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Rotating Belt / Pulley
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Details:
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Suspended Weight
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Details:
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Other:
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Details:
