Salt Water Disposal Facility

• Conducted On:

  Date

• Location:

• RRC #:

• Operator #:

• Site Representative:

• Safety Representative:

• Status of Operations:

Signage:

• Safety Billboard in Place?

  Yes

  No

  N/A

• PPE & FRC's signage in Place at Entrance?

  Yes

  No

  N/A

• Lease Signs in Place?

  Yes

  No

  N/A

• No Smoking Signage at the Entrance of Location?

  Yes

  No

  N/A

• Confined Space Labels in Correct Location on Tanks?

  Yes

  No

  N/A

• Tanks Labeled with Placards in Place?

  Yes

  No

  N/A

• Chemicals Labeled?

  Yes

  No

  N/A

• Generator Fuel Tank Labeled?

  Yes

  No

  N/A

• Electrical Room Labeled?

  Yes

  No

  N/A

• Electrical Breakers Properly Indicated?

  Yes

  No

  N/A

• Electrical Board Panels with Warning Labels in Place?

  Yes

  No

  N/A

• Pumping Unit Safety Warning Labels in Place?

  Yes

  No

  N/A

• All Containers Labeled with their Contents?

  Yes

  No

  N/A

• Hearing Protection Signage in Place?

  Yes

  No

  N/A

• Automatic Start Signage in Place?

  Yes

  No

  N/A

• Stay Off Berm Signage in Place?

  Yes

  No

  N/A

Applicable Permits

• JSA / SJA Completed with Contractor Sign-in Sheet?

  Yes

  No

  N/A

• Ground Disturbance Permit Completed?

  Yes

  No

  N/A

• Hot Work Permit Completed?

  Yes

  No

  N/A

• Confined Space Permit Completed and Posted?

  Yes

  No

  N/A

• Critical Lift Permit Completed?

  Yes

  No

  N/A

General Site Inspection:

• Interior / Exterior Berm in Place?

  Yes

  No

  N/A

• Valve Closed and Secured for drainage of location?

  Yes

  No

  N/A

• All Caps and Plugs in Place?

  Yes

  No

  N/A

• Plumbing Appeared to Teflon Tape or thread coating on all Threads?

  Yes

  No

  N/A

• Tanks, Walkways, Stairs Properly Grounded?

  Yes

  No

  N/A

• Grounds Available for Transport while Loading and Unloading?

  Yes

  No

  N/A

• Stairs and Catwalk Secured on Tanks with Two Threads Showing on Bolts?

  Yes

  No

  N/A

• Adequate Hand-Rails Provided on Stairs and Catwalk?

  Yes

  No

  N/A

• Windsock Up and Visible and in Good Shape?

  Yes

  No

  N/A

• Are Chemicals Stored Properly with SDS Available?

  Yes

  No

  N/A

• Electrical Covers in Place?

  Yes

  No

  N/A

• Location Clean with Pathways Clear (No Obstructions)?

  Yes

  No

  N/A

Crew and Equipment Inspection

• All Crew Members Wearing Proper PPE & FRC's?

  Yes

  No

  N/A

• H2S Monitors Being Utilized?

  Yes

  No

  N/A

• Fall Protection Being Utilized?

  Yes

  No

  N/A

• Crew Utilizing Proper Tools for Job Functions?

  Yes

  No

  N/A

• Crew Using Proper Lifting Techniques?

  Yes

  No

  N/A

• Machinery with Safety Guards in Place?

  Yes

  No

  N/A

• Good Housekeeping with Work Area Clean and Organized?

  Yes

  No

  N/A

• Crew Utilizing Proper Lockout / Tag Out?

  Yes

  No

  N/A

• Does any Equipment on Location Appear to Have Any Fluid Leaking?

  Yes

  No

  N/A

• Are Chock Blocks Being Utilized?

  Yes

  No

  N/A

General Facility Inspection Salt Water Disposal

• First Aid Kits are Up to Date and Available?

  Yes

  No

  N/A

• Eye Wash Station Up to Date and Available?

  Yes

  No

  N/A

• Hearing Protection Available?

  Yes

  No

  N/A

• Flammable Storage Cabinet Being Utilized?

  Yes

  No

  N/A

• SDS Binders at Location with Updated SDS Sheets?

  Yes

  No

  N/A

• Are Combustibles Being Kept in Electrical Room?

  Yes

  No

  N/A

• Is all Electrical Wiring Incased in Conduit with Covers in Place?

  Yes

  No

  N/A

• Are Rubber Mats in Place on Flooring of Electrical Building?

  Yes

  No

  N/A

• Are All Transformers Enclosed with Safety Barrier (Bollards)?

  Yes

  No

  N/A

• Underground Injection Control (UIC) Permit Available?

  Yes

  No

  N/A

• Spill Prevention Control and Countermeasure Plan (SPCC) Available?

  Yes

  No

  N/A

• Facilities Response Plan (FRP) Available?

  Yes

  No

  N/A

• Fire Extinguishers Available with Monthly/ Annual Inspection Completed?

  Yes

  No

  N/A

Additional Findings or Concerns:

• Issue #1:

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• Issue #2:

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• Issue #7:

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• Issue #8:

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• Issue #9:

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• Issue #10:

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• Safety Representative:

• Add signature

  Sign

• Supervisor / Foreman / Person in Charge (PIC):

• Add signature

  Sign