New or Altered E/P/A Release Form

• Site conducted:

  Select

• Conducted on:

  Date

• Prepared by:

• Equip/Process/Area:

• Department:

• Model/Serial/ID# :

• Function/Description/Purpose:

• New or Altered:

• List persons involved in Safety Review Inspection

• Are any items on the E/P/A Safety Review marked Unsatisfactory?

  Yes

  No

• If answer is yes then describe Unsatisfactory Safety Issue and create an action to eliminate/mitigate.

Signatures

• THIS CERTIFIES THAT: I HAVE PERSONALLY INSPECTED THIS NEW OR ALTERED EQUIPMENT/PROCESS /AREA, AND ALL IDENTIFIED HEALTH AND/OR SAFETY HAZARDS ARE PROPERLY CONTROLLED; ENVIRONMENTAL CONCERNS ADDRESSED; AND I HAVE FOUND IT ACCEPTABLE TO RELEASE FOR NORMAL PRODUCTION OPERATIONS.

• Mgmt:

  Sign

• Maint:

  Sign

• Engng:

  Sign

• Quality:

  Sign

• EHS:

  Sign

• * Conditional EHS certifications shall not be made.
  ** Above named persons shall all be representatives of said departments and are to be assigned by Dept. Head.
  *** Assigned Dept. Reps shall be competent in the scope & operation(s) of the Equip/Process/Area named on line #1
  

• HEALTH /SAFETY / ENVIRONMENTAL / CERTIFICATION INSTRUCTIONS
  
  1. EHS CERTIFICATION INSPECTION IS TO BE CONDUCTED AND THIS FORM COMPLETED WHENEVER:
  A) A NEW PIECE OF EQUIPMENT OR PROCESS IS INSTALLED.
  B) WHEN AN EXISTING PIECE OF EQUIPMENT/PROCESS/AREA HAS BEEN ALTERED. THIS INCLUDES, BUT IS NOT LIMITED TO, CHANGES IN OPERATING REQUIREMENTS/CONDITIONS OR ADDITION/DELETION OF EHS. DEVICES.
  
  2. DO NOT SIGN THIS CERTIFICATE UNTIL YOU ARE SATISFIED THE EQUIPMENT/PROCESS/AREA IS ACCEPTABLE TO OPERATE AS IS AND YOU HAVE PERSONALLY INSPECTED THE EQUIPMENT/PROCESS/AREA. ENSURE ALL PERTINENT DOCUMENTS HAVE BEEN RETAINED, SUCH AS MAINTENANCE/OPERATING/PARTS MANUALS.
  
  3. NO "CONDITIONAL" EHS CERTIFICATIONS ARE TO BE MADE. IF THE EQUIPMENT/PROCESS/AREA IS NOT ACCEPTABLE TO OPERATE AS IS, DO NOT SIGN THIS FORM. RESEARCH OR OTHER EXPERIMENTAL RUNS MAY BE CERTIFIED UNDER THE CONDITIONS OF THE EXPERIMENT AS LONG AS THE HEALTH & SAFETY OF THE EMPLOYEES IS PROTECTED.
  
  4. FAILURE TO COMPLY WITH 2-3 WILL BE CONSIDERED FALSIFICATION OF RECORDS AND WILL BE DEALT WITH ACCORDINGLY.
  

• COMPLETION OF FORM
  1. All pages and sections of form must be completed.
  2. Legibly printed name, corresponding signature, date, and time must be entered on form.
  3. If any of the 5 Dept. Representatives conducting the EHS Release of New or Altered Equipment/Process/Area form do not sign for their Department the Equipment/Process/Area identified on line 1 will not be released for normal operations. “Unsatisfactory” items checked on page 1 of form must be listed & described on page 2 of form. Recommendations to satisfy deficiencies can also be entered on page 2.
  4. Self-explanatory: Including and up to termination
  

• FORM DISTRIBUTION: Management, Maintenance, Engineering, Quality, EHS