Title Page
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Site conducted
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Conducted on
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Surveillance Month
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Prepared by
Fire Extinguisher No. 1
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
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Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 2
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
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Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 3
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
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Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 4
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
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Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 5
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
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Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 6
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
-
Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 7
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
-
Does the gauge show in the green (Fully Charged)?
-
Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 8
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
-
Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 9
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
-
Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 10
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
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Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 11
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
-
Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 12
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
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Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 13
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
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Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 14
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
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Does the gauge show in the green (Fully Charged)?
-
Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 15
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
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Is pin intact?
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Is the anti-tamper seal intact?
-
Does the gauge show in the green (Fully Charged)?
-
Is the service company tag attached, signed and dated?
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Concerns Identified?
Fire Extinguisher No. 16
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Is the fire extinguisher unobstructed and accessible?
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Is the fire extinguisher safely secured/won't fall easily?
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Are the operating instructions on nameplate legible?
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Is the nozzle intact?
-
Is pin intact?
-
Is the anti-tamper seal intact?
-
Does the gauge show in the green (Fully Charged)?
-
Is the service company tag attached, signed and dated?
-
Concerns Identified?
Closeout
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Other Concerns Identified?
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Completed By: