Title Page

  • Document Number

  • Site Name

  • Site Name

  • Caltex Site ID

  • Conducted on

  • Prepared by


Operations Register/Contractor paper work

  • Is the "Milemaker Operations register" available on site? (Version 4)

  • Does the site have a folder with all contractors work sheet, JSA, work permit, or WPCG permit attached?

Licences and certificates

  • Does site have a Milemaker emergency contact list at the console?

  • Is the current and valid dangerous good licence on display?

  • Is the emergency flip chat (June 2013) up to date with current telephone numbers available at the console?

  • Is the site currently registered as a food selling business?<br>View and note licence number.

  • Is the a map outlining the site evacuation procedure including an evacuation point and escape route on display?


  • Does the site have a diary or a communications book for recording customer concerns and or communicating to staff?

Site Self Audit

  • Are the Milemaker Monthly store hazard/risk audit sheets being completed?

PA System

  • Is there a public address system, and is it operational? (Test)

Emergency Stop

  • Are all "emergency stop" switches readily accessible, with no items blocking access and operational?

  • Does the site perform an emergency evacuation drill regularly, is this documented? Record last date?

Electrical Equipments

  • Is all portable electrical equipment tested and tagging in date?

  • Are all red power points free of any foreign appliances? <br>(Kettles, toasters, phone chargers, etc)

Training records

  • Does the site have a current employee list which records staff training completed in any/all of the following

  • Fire training

  • Spill kit training

  • Emergency response training

  • First aid training

  • Food safety training

  • LPG training

  • BBQ gas bottle training

LPG Gas- Auto gas and decanting

  • Does site have a "Caltex LPG operations manual"? (Version June 2012)

  • Is the "Caltex site occupier LPG daily & weekly inspection record" being completed?

  • Has each pump dispenser breakaway coupling been tested and recorded? Note the last test date.

Food hygiene

  • Does the site possess a Caltex HACCP food safety plan?

  • Does the site have a qualified food safety supervisor? View certificate, noting name and date.

  • Is all food currently with their expiry date? <br>Spot check.

  • Does the site have a working thermometer?

  • Has the thermometer been calibrated? (Probe- Water and ice. Laser- calibration kit) and is it bring recorded monthly?

  • Is the daily monitoring schedule being completed daily?

  • Is food preparation sink clean, sanitising soap and paper towel available?

  • Is all PPE in good conditions? (Gloves, bakery trays, tongs)

  • Is all food prep and display areas clean and free of spill and crumbs?

  • Is there a system in place for the "in and out" times for the food with in the HAC units?

  • Can the site provide a copy of a pest control service report including sighting register, bait station map, MSDS and current contractor licence?

Incident reporting

  • Is the operator able to describe the correct procedures to follow in the event of an incident?

  • Does site have blank incident reports available?

  • Does the site have current incident reports completed and filed correctly?

Fire Equipment Interior

  • Does site have at least 1 fire extinguisher in the sales showroom and or behind the console?

  • Does the site have a fire extinguisher in the vicinity of the electrical switchboards?

  • Does all interior fire extinguishers poses a metallic tag with dates of previous service not more then 6 months previous?

  • Do all interior fire extinguisher locations have current signage in place?

Exit Lighting

  • Are all exit signs and emergency lighting been maintained in an operable conditions?

  • Is the view or identification of exit signs obstructed?

Door Signage

  • Does the entranceway posses height stickers on the door frame to assist in height estimates?

  • Is there decal asking customers to 'remove helmets' prior to entering the store?

  • Can the console operator clearly see all areas of the forecourt with out having to look around obstructions?

General Fire Safety

  • Are paths ways and isles clear?

  • Are rubbish and combustible materials disposed of appropriately on a regular basis?

  • Is there a sharps container and handling procedure?

  • Is the correct ladder/safety steps being used? (No milk creates)

  • Are all items in the store room stored safely not stacked above shoulder height?

  • Is the store room clean and tidy, no obstacles or trip hazards?

  • Is the store room & console are free of any LPG cylinders stored inside?

Site Emergency Equipment

  • Is the touch available to employees intrinsically safe?

  • Are thermally insulated gloves for emergency use (LPG) readily assessable?

  • Does the site possess protective eye ware for LPG decanting?

  • Are 2 spare LPG metal fill valve caps readily accessible for emergency use?

  • Are at least 2 reflective vests readily available?

  • Is there at least 3x 700mm high reflective safety cones available for forecourt work and traffic management?

  • Does the site have adequate wet floor/hazard warning signs?

  • Is all safety equipment together and located in an accessible location behind the console?

  • Is all safety equipment/PPE in good conditions?

First Aid Kit

  • Does the site posses a first aid kit?

  • Is the first aid kit placed in a position where the console operator can readily access it at all times?

  • Is the first aid kit free of all out of date stock?

  • Is the first aid kit free of paracetamol and aspirin based medication?

Cash Handling Security

  • Does the cash draw contain less then $300?

  • Is the console area free any unsecured cash, change or spare float?

Security System CCTV

  • Is there a camera pointed in the direction of the point of sale counter?

  • Is there a camera on site that covers the main public entrence to store?

  • Can the customer see the CCTV image on the monitor as the perform their transactions?

  • Is the console camera focused at the customer at the console? (Rather than the stock or cash draw)

  • Does the console camera clearly show the the customer features so that they can be recongnized?

Panic Duress Alarm

  • Is there a duress/panic alarm at the console?

  • Is the duress alarm immediately accessible? (Not blocked by stock)

  • Are there records of monthly testing of the duress alarm switches?

Fuel Water Testing

  • Does the site have suffice to water paste on site?

  • Does the site conduct weekly water paste tests?

  • Does the site keep a record of water paste tests?


Dip and fill points

  • Are the fill and dip points securely marked with circular discs and numbers of durable materials?

  • Are fill and dip caps present on site and have the ability to be secured?

  • Do all fill and dip points possess a rubber or leather seal to prevent water entering the tank?

  • Do dipsticks have safe fill levels marketed on them?

  • Are dip sticks free of any bends breaks or worn areas?

Spill Box

  • Is the spill boxer drain valve sealing correctly? (Test)

  • Is the spill box cleaned and free of mud leaf litter and water?

Fuel Dispensers

  • Are all pump/dispensers in good working order?

  • Are all pump/dispensers hoses free from cracks or damage? (Detail those that are not)

  • Are the pump/dispensers area free of any evidence of fuel spill?

  • Are all your pump/dispensers cabinets free from any damage? (Please detail those which are not)

  • Are all pumps/dispensers and columns numbered?

  • No ignition sources located in hazardous area?

  • Are all dispensers protected from impact by vehicles and trailers?

  • Are all LPG hoses fitted with self sealing break coupling?


  • Do all LPG pumps/dispensers have "Filling instructions" in place?

  • Do all "Emergency Stop" bottoms both at the dispenser and other locations have Emergence Procedure decals and identified as stop buttons?

  • Are the following decals in place and legible? "Stop engine" and "No Smoking"

  • Is signage for filling advertised on columns

External Safety Markers

  • Are there "HAZCHEM" signs at all entrance to site?

  • Are all dangerous steps/concrete painted yellow?

LPG Gas Tank (above ground)

  • Is LPG tank well protected? (Adequate railing/barriers)

  • Is all Emergency signage and placarding in place at the LPG tank? (Including "Flammable Gas" Dimond, no smoking, 2YE, correct emergency number)

  • Is the correct emergency contact phone number on LPG signage CALTEX 0448 830 445?

  • Is the area around the LPG tank clear of obstructions?

  • Is LPG tank in good conditions? (No evidence of damage or corrosion)

  • Is the LPG pipe work in good condition? (No evidence of damage or corrosion)

  • Is the lid/cover of the LPG tank locked?

  • Does the LPG tank fill valve posses a cap?

  • Does the pressure relief valve posses a cap?

  • Is the tank test date with in the last ten (10) years? (Record date and serial number of test)

LPG Tank Below Ground

  • Does the site have a Gatwick lifter for opening the turret lid?

  • Is the tank turret free from any water or rubbish?

  • Is the tank test date with in the last ten (10) years? (Record date of test and serial number)

  • Is the LPG fill point marked?

Air Compressor

  • Does the air compressor have proper belt guard?

  • Is the compressor being emptied of water and oil checked weekly, are records being recorded to show?

Spill Kit

  • Does the site posses a spill control kit?

  • Does the spill kit contents meet stock requirement? (Check stock levels using the checklist provided)

  • Is the spill kit located adjacent to the shop entrance on the forecourt?

  • Is the spill kit adequately identified?

Fire Extinguisher External

  • Are the fire extinguishers "dry chemical" marked with a white band?

  • Does all fire extinguishers have appropriate signage?

  • Are the extinguishers fully charged with a test date stamped on maintenance tag? (Not more then 6 months previous)

  • Are all extinguishers mounted in red boxes?

  • Does the site have a 003 key to open the fire extinguisher box?

  • Are all fire extinguishers in an appropriate location that is easily accessible?

Fire Hose Reel

  • Does the fire hose reel posses a metallic tag with dates of previous service, not more then 6 months previous?

  • Is the fire hose reel stored neatly, not tangled, free of kinks and leaks?

  • Are the operating instructions clear and legible?

  • Is the fire hose reel accessible at all times?

Fire Hydrant

  • Does the site have fire hydrant? (If no mark NA)

  • Is the hydrant easily accessible and free from hazards?

Manifest Box

  • Is the emergency information manifest box located in an easily accessible locations?

  • Is the cabinet weather proof, clearly visible and correctly labeled?

  • Is the cabinet lockable with 003 key, does the site have key on site?

  • Is the folder located in the box, is it up to date and signed off by fire authorities with in the last 5 years? (site layout drawing, manifest drawings, on and off-site emergency contact list, evaluation points, emergency procedures and current MSDS)

Decanting Gas

  • Does the site have decanting gas cylinders? (If no, please mark as NA and more to BBQ gas cylinders)

  • Is LPG decanting cylinders locked?

  • Are LPG decanting cylinders at least 5m from a source of ignition and combustible materials?

  • Are LPG decanting cylinder at least 2m from doorway, vent, or open window?

  • Are LPG decanting cylinders at least 5m from building on the neighbouring property?

  • Are LPG decanting cylinders at least 3m from a drain or pit?

  • Are LPG decanting cylinders free of any device to keep the dead mans handle open? Eg cable ties, hose clamp. REOMVE IMMEDIATELY.

  • Is there a fire extinguisher located adjacent to the filling area?

  • Are LPG Exchange cylinders at least 5m from above ground LPG tank?

  • Are LPG exchange cylinders at least 1.5m(height) & 0.5m (width) from a source of ignition, drain pit, or site boundary?

  • Are LPG exchange cylinders at least 1m from a door way, vent or open window?

  • Are LPG exchange cylinders at least 0.5m from combustible materials?

  • Are LPG exchange cylinders cage sturdy, stable and clear on at least two sides?

  • Where there are two cages are they at least 3m apart?

  • Is the dangerous goods class label (250mm square) and "flammable gas- No smoking" label on the front of the cage?

Car Wash

  • Is the car wash plant room neat and tidy wth no spills or trip hazard?

  • Is the daily/weekly car wash checklist being completed?

Tank Dipping Observations

  • Did the operator use correct PPE and 3x safety cones whilst dipping fuel tanks?

  • Did the operator use clean rag or paper towel to wipe the dip stick?

  • Did the operator position themselves facing the traffic?

  • Did the operator remove the dipstick hand over hand?

  • Did the operator dip two or three times before recording the tank dip?

  • Did the operator check if the leather seal was in place prior to replacing the dip cap?

  • Did the operator lower the dip stick gently not letting it free fall?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.