Sample: General Workplace

• Audit TitleC-STORE

• Client / SiteAG VALLEY COOP

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Yes

  No

  N/A

1.0 - FUEL PUMP AREA

• 1.1 - Is the pump area well stocked and clean?

  Yes

  No

  N/A

• 1.2 - Is required signage in place and in good condition?

  Yes

  No

  N/A

• Emergency shut off clearly marked?

  Yes

  No

  N/A

• Emergency telephone well identified?

  Yes

  No

  N/A

• Are emergency contact numbers clearly posted with current information?

  Yes

  No

  N/A

2.0 - INSIDE THE STORE

• 2.1 - Emergency exits well marked?

  Yes

  No

  N/A

• 2.2 - Emergency lighting in place and operational?

  Yes

  No

  N/A

• 2.3 - Aisles are clear and uncluttered?

  Yes

  No

  N/A

• 2.4 - Extinguishers inspections documented?

  Yes

  No

  N/A

• 2.5 - Extinguishers clear of obstructions?

  Yes

  No

  N/A

• 2.6 - No slip or trip hazards identified?

  Yes

  No

  N/A

• 2.7 - Electrical cords are all properly grounded?

  Yes

  No

  N/A

• 2.8 - Electrical cords in good condition (no breaks, exposed wires, pulled connections at plug ends)?

  Yes

  No

  N/A

• 2.9 - Electrical cords are properly used and protected against abrasion?

  Yes

  No

  N/A

3.0 - FOOD PREPARATION AREA

• 3.1 - Access is clear and uncluttered?

  Yes

  No

  N/A

• 3.2 - Floor surface clean and slip hazards removed?

  Yes

  No

  N/A

• 3.3 - Electrical connections are safe and complete (no missing covers, etc)?

  Yes

  No

  N/A

4.0 - UNDERGROUND TANK INFORMATION

• 4.1 - Employee is able to provide UG Tank Book?

  Yes

  No

  N/A

• 4.2 - Emergency contacts current?

  Yes

  No

  N/A

• 4.3 - Copies of all A,B &C Operator Certificates applicable to the location are available?

  Yes

  No

  N/A

• 4.4 - Daily inventory reconciliation records are current and available for 5 years?

  Yes

  No

  N/A

• 4.5 - Cathodic protection records -at least 6 years records- available?

  Yes

  No

  N/A

• 4.6 - Line leak detection test results available for at least 5 years?

  Yes

  No

  N/A

• 4.7 - Department of Weights and Measures Meter Test Results for last 5 years?

  Yes

  No

  N/A

• 4.8 - Are fall preventive measures in place and used where gaps occur in railings?

  Yes

  No

  N/A

• 4.9 - Are monthly tank tightness tests or SCALD records available for 5 years?

  Yes

  No

  N/A

5.0 - POLICIES

• 5.1 - Emergency Ation Plan is available and updated?

  Yes

  No

  N/A

• 5.2 - Employees know where the rendezvous location (primary and secondary) are for the location?

  Yes

  No

  N/A

• 5.3 - Employees know who to call in case of emergency?

  Yes

  No

  N/A

• 5.4 - Employees have discussed and planned for severe weather events?

  Yes

  No

  N/A

6.0 - ADDITIONAL STORAGE AREAS

• 6.1 - Shelving units are secure, stable, and organized?

  Yes

  No

  N/A

• 6.2 - Adequate spacing between shelf units?

  Yes

  No

  N/A

• 6.3 - Exits clear and passageways unobstructed?

  Yes

  No

  N/A

11.0 LADDERS

• 11.1 - Are all ladders Industrial strength? (Non Household rated, check label.)

  Yes

  No

  N/A

• 11.2 - Are ladders in good condition?

  Yes

  No

  N/A

12.0 - FIRST AID

• 12.1 - Are cabinets and contents clean and orderly?

  Yes

  No

  N/A

• 12.2 - Are contents regularly checked?

  Yes

  No

  N/A

• 12.5 - Is there easy access to cabinets?

  Yes

  No

  N/A

• 12.6 - Employees aware of location of first aid cabinet?

  Yes

  No

  N/A

ADDITIONAL NOTES OR INFORMATION

• Are there any other issues noted?

  Yes

  No

  N/A

Sign Off

• On site representative

  Sign

• Auditor's signature

  Sign