The NACHER Corporation Tank Cleaning Division

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

LOCATION PERSONNEL

• CUSTOMER REPRESENTATIVE

• SAFETY OFFICER

• NACHER FOREMAN

• NACHER crew members: Note any SSE Personnel and mentors by (SSE/M)

SITE RECORDS

• Work Pack

  Yes

  No

  N/A

• JSA's

  Yes

  No

  N/A

• Signed BMP Plan

  Yes

  No

  N/A

• Paint MSDS's

  Yes

  No

  N/A

• BBS Cards

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

PROCEDURES

• Nacher safety policies and procedures

  Yes

  No

  N/A

• Work permit

  Yes

  No

  N/A

• JSA reports

  Yes

  No

  N/A

• Hot work permit

  Yes

  No

  N/A

• Lockout/tagout permit

  Yes

  No

  N/A

• Confined space permit

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

STORAGE FACILITES

• Is an inventory of hazardous chemicals conducted annually?

  Yes

  No

  N/A

• Does the inventory include location of each hazardous chemical?

  Yes

  No

  N/A

• Are MSDS's on hand for all chemicals listed on inventory and used on the project?

  Yes

  No

  N/A

• Do employees know how to read MSDS's?

  Yes

  No

  N/A

• Are MSDS's kept in one or more key places, and readily available to all concerning employees?

  Yes

  No

  N/A

• Are chemicals and solvents kept in properly labeled and approved containers?

  Yes

  No

  N/A

• Are labels present on all hazardous chemical containers?

  Yes

  No

  N/A

• Do employees follow safe work practices when working with hazardous materials (i.e., check labels and MSDS, follow safety instructions, use required PPE)?

  Yes

  No

  N/A

• Is hazard communication plan readily available for all employees?

  Yes

  No

  N/A

• Equipment

  Safe

  At Risk

  N/A

• Tool House

  Safe

  At Risk

  N/A

• Waste Materials

  Safe

  At Risk

  N/A

• Other (specify below)

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

FIRST AID CONTENTS

• 10 man safety kits

  Yes

  No

  N/A

• Eye wash stations with refills

  Yes

  No

  N/A

• Are first aid kits available and adequately stocked?

  Yes

  No

  N/A

• Are first aid kits approved by physician?

  Yes

  No

  N/A

• Are there first aid/CPR trained personnel available?

  Yes

  No

  N/A

• Is that list posted on first aid kits?

  Yes

  No

  N/A

• Are emergency eye washes available?

  Yes

  No

  N/A

• Are emergency showers available?

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

ENVIRONMENT

• VENTILATION

  Yes

  No

  N/A

• 1. Is tank properly ventilated and blower tied off?

  Yes

  No

  N/A

• LIGHTING

  Yes

  No

  N/A

• 1. Are lighting systems non-explosion specific?

  Yes

  No

  N/A

• ACCESS TO/FROM WORK SITE

  Yes

  No

  N/A

• OXYGEN/GAS MONITORING EQUIPMENT (LEL MONITORS)

  Yes

  No

  N/A

• EMERGENCY ROUTE TO MUSTER AREA

  Yes

  No

  N/A

• 1. Is there a contingency plan for the facility?

  Yes

  No

  N/A

• 2. Are employees familiar with the contingency plan?

  Yes

  No

  N/A

• 3. Have emergency escape routes been designated and posted?

  Yes

  No

  N/A

• 4. Are employees familiar with the emergency signals?

  Yes

  No

  N/A

• 5. Are employees familiar with emergency procedures?

  Yes

  No

  N/A

• 6. Are emergency telephone numbers posted?

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

COMPRESSORS

• FILTER MEDIA ON AIR INTAKES

  Safe

  At Risk

  N/A

• AIR FILTERS AND CHANGE DATE STICKER

  Safe

  At Risk

  N/A

• FAN BLADES AND BELTS

  Safe

  At Risk

  N/A

• RADIATOR

  Safe

  At Risk

  N/A

• STARTER / SOLENOID

  Safe

  At Risk

  N/A

• STARTER WIRES

  Safe

  At Risk

  N/A

• FUEL FILTERS AND DATE CHANGE STICKERS

  Safe

  At Risk

  N/A

• RACOR FUEL FILTERS AND DATE CHANGE STICKERS

  Safe

  At Risk

  N/A

• AIR SUPPLY TANK

  Safe

  At Risk

  N/A

• EMERGENCY SHUT DOWN DEVICE

  Safe

  At Risk

  N/A

• MUFFLER / EXHAUST SYSTEM

  Safe

  At Risk

  N/A

• INJECTOR LINES

  Safe

  At Risk

  N/A

• COMPRESSOR FLUID AND AIR HOSES

  Safe

  At Risk

  N/A

• FLUID LEAKS

  Safe

  At Risk

  N/A

• IS COMPRESSOR PROPERLY GROUNDED

  Safe

  At Risk

  N/A

• AIR QUALITY PAPERWORK POSTED

  Safe

  At Risk

  N/A

• EXHAUST AND MANIFOLD INSULATION

  Safe

  At Risk

  N/A

• STAINLESS ARMOR HOSES

  Safe

  At Risk

  N/A

• FUEL SHUTOFF TIED INTO PLATFORM ESD

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

COMPRESSOR FLUID LEVELS AND OPERATING CONDITIONS

• RADIATOR

  Safe

  At Risk

  N/A

• AIR END OIL

  Safe

  At Risk

  N/A

• ENGINE OIL

  Safe

  At Risk

  N/A

• AIR TEMPERATURE

  Safe

  At Risk

  N/A

• OPERATING TEMPERATURE

  Safe

  At Risk

  N/A

• ALTERNATOR GAUGE

  Safe

  At Risk

  N/A

• PRESSURE GAUGE

  Safe

  At Risk

  N/A

• AIR START AIR TANK PRESSURE

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

VACUUM SYSTEMS

• GENERAL CONDITION

  Safe

  At Risk

  N/A

• OIL

  Safe

  At Risk

  N/A

• FILTER

  Safe

  At Risk

  N/A

• HOSES

  Safe

  At Risk

  N/A

• ELECTRICAL LINES

  Safe

  At Risk

  N/A

• SLINGS

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

PRESSURE WASHERS

• GENERAL CONDITIONS

  Safe

  At Risk

  N/A

• OIL

  Safe

  At Risk

  N/A

• FILTER

  Safe

  At Risk

  N/A

• HOSES

  Safe

  At Risk

  N/A

• ELECTRICAL LINES

  Safe

  At Risk

  N/A

• SLINGS

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

PRODUCTION CONEX

• CLEANLINESS

  Safe

  At Risk

  N/A

• SLINGS

  Safe

  At Risk

  N/A

• EQUIPMENT STORAGE

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

AIR HOSES

• HOSES

  Safe

  At Risk

  N/A

• CLAMPS

  Safe

  At Risk

  N/A

• SAFETY WIRE / CLIPS

  Yes

  No

  N/A

• WHIP CHECKS

  Safe

  At Risk

  N/A

• 1. All hoses and pressured lines secured

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

DIA PUMPS

• GENERAL CONDITION

  Safe

  At Risk

  N/A

• FILTER

  Safe

  At Risk

  N/A

• HOSES

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

SUPPLIED AIR SYSTEM

• GENERAL CONDITION

  Safe

  At Risk

  N/A

• CURRENT CERTIFICATION

  Yes

  No

  N/A

• FILTER / WATER POD

  Safe

  At Risk

  N/A

• HOSES

  Safe

  At Risk

  N/A

• 5-MINUTE SCBA's

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

VOLUME TANK

• PRESSURE RELIEF VALVE

  Safe

  At Risk

  N/A

• BALL VALVES

  Safe

  At Risk

  N/A

• PRESSURE GAUGE

  Safe

  At Risk

  N/A

• EQUIPMENT GROUNDED

  Safe

  At Risk

  N/A

• PETCOCK VALVE

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

TOOL HOUSE

• APPEARANCE

  Safe

  At Risk

  N/A

• SECURITY

  Safe

  At Risk

  N/A

• MSDS POSTED / CURRENT

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

CREW LIVING QUARTERS

• APPEARANCE

  Safe

  At Risk

  N/A

• CLEANLINESS

  Safe

  At Risk

  N/A

• PERSONAL ITEMS STORED IN LOCKER AND LOCKED

  Yes

  No

  N/A

• LIFE JACKETS AVAILABLE

  Yes

  No

  N/A

• GAS DETECTOR / ALARMS IN PLACE AND PROPERLY SERVICED

  Yes

  No

  N/A

• ORGANIZATIONAL LAYOUT

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

RIGGING EQUIPMENT

• ALUMINUM BOARDS

  Safe

  At Risk

  N/A

• OSHA BOARDS (CLEATS)

  Safe

  At Risk

  N/A

• CABLE CLAMPS

  Safe

  At Risk

  N/A

• CABLE

  Safe

  At Risk

  N/A

• MOON AND HLL CLAMPS

  Safe

  At Risk

  N/A

• SNATCH BLOCKS

  Safe

  At Risk

  N/A

• THIMBLES

  Safe

  At Risk

  N/A

• SHACKLES

  Safe

  At Risk

  N/A

• CHOKER CABLES

  Safe

  At Risk

  N/A

• LADDERS

  Safe

  At Risk

  N/A

• SAFETY NETS AND HOOKS

  Safe

  At Risk

  N/A

• NEEDLE BEAMS

  Safe

  At Risk

  N/A

• STANDOFFS

  Safe

  At Risk

  N/A

• SCAFFOLDING

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

PERSONAL SAFETY EQUIPMENT

• BODY HARNESS

  Safe

  At Risk

  N/A

• FACE SHIELD

  Safe

  At Risk

  N/A

• GLOVES

  Safe

  At Risk

  N/A

• HARD HATS

  Safe

  At Risk

  N/A

• LIFE JACKET / WORK VEST

  Safe

  At Risk

  N/A

• SAFETY GLASSES

  Safe

  At Risk

  N/A

• SAFETY GOGGLES

  Safe

  At Risk

  N/A

• STEEL TOE BOOTS

  Safe

  At Risk

  N/A

• HEARING PROTECTION

  Safe

  At Risk

  N/A

• TYVEK SUITS

  Safe

  At Risk

  N/A

• DUST MASKS

  Safe

  At Risk

  N/A

• RESPIRATOR

  Safe

  At Risk

  N/A

• TURTLE SKIN

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

MATERIALS (List of site specific)

• A.

  Yes

  No

  N/A

• B.

  Yes

  No

  N/A

• C.

  Yes

  No

  N/A

• D.

  Yes

  No

  N/A

• E.

  Yes

  No

  N/A

• F.

  Yes

  No

  N/A

• G.

  Yes

  No

  N/A

• H.

  Yes

  No

  N/A

• I.

  Yes

  No

  N/A

• J.

  Yes

  No

  N/A

• K.

  Yes

  No

  N/A

• L.

  Yes

  No

  N/A

PLATFORM EQUIPMENT PROTECTION

• ACTUATED VALVES

  Safe

  At Risk

  N/A

• AID TO NAVIGATION LIGHTS

  Safe

  At Risk

  N/A

• BUILDING AIR VENTS

  Safe

  At Risk

  N/A

• DRAINS

  Safe

  At Risk

  N/A

• ELECTRIC MOTORS

  Safe

  At Risk

  N/A

• ELECTRICAL EQUIPMENT

• 1. Are live electrical components de-energized prior to working on or near them?

  Yes

  No

  N/A

• 2. Is equipment that is de-energized, but is not locked or tagged out treated as energized?

  Yes

  No

  N/A

• 3. Are safety signs and tags used to warn employees about electrical hazards?

  Yes

  No

  N/A

• 4. Are barricades and/or attendants used where necessary to prevent or limit employee access to electrical hazards?

  Yes

  No

  N/A

• 5. Is personal protective equipment used when required?

  Yes

  No

  N/A

• 6. Are motors clean and free of excessive dirt and oil?

  Yes

  No

  N/A

• 7. Are portable lights equipped with proper guards?

  Yes

  No

  N/A

• 8. Are qualified electricians only allowed to work on electrical systems?

  Yes

  No

  N/A

• COMPRESSOR COOLING FANS

  Safe

  At Risk

  N/A

• ENGINE INTAKE FILTERS

  Safe

  At Risk

  N/A

• TURBINE INTAKE FILTERS

  Safe

  At Risk

  N/A

• FIRE EXTINGUISHERS

• 1. Are adequate numbers of fire extinguishers of appropriate type available?

  Yes

  No

  N/A

• 2. Are employees trained with portable fire extinguishers?

  Yes

  No

  N/A

• 3. Are fire lanes established and maintained?

  Yes

  No

  N/A

• 4. Are fire extinguishers mounted at readily accessible locations and free of obstructions?

  Yes

  No

  N/A

• 5. Are fire extinguishers inspected monthly and noted on the tag?

  Yes

  No

  N/A

• 6. Is the facility fire drill held monthly and documented?

  Yes

  No

  N/A

• 7. Are combustible materials prohibited from being stored under stairways?

  Yes

  No

  N/A

• 8. Are fire doors unobstructed inside and outside and in good operating condition?

  Yes

  No

  N/A

• 9. Is a "No Smoking" policy in place for designated areas and enforced?

  Yes

  No

  N/A

• 10. Are there metal containers designated for cigarette butts in designated "Smoking Areas"?

  Yes

  No

  N/A

• 11. Is a "No Smoking" policy in place for designated areas and enforced?

  Yes

  No

  N/A

• 12. Is the fire alarm system inspected annually?

  Yes

  No

  N/A

• 13. Are flammable and combustible storage areas properly marked with signs?

  Yes

  No

  N/A

• FIRE HOSE REELS

  Safe

  At Risk

  N/A

• GAUGES

  Safe

  At Risk

  N/A

• LIFE RAFTS

  Safe

  At Risk

  N/A

• LIFE RINGS

  Safe

  At Risk

  N/A

• LIGHT FIXTURES

  Safe

  At Risk

  N/A

• PANELS

  Safe

  At Risk

  N/A

• PILOT BOXES

  Safe

  At Risk

  N/A

• SAND BLOWERS

  Safe

  At Risk

  N/A

• SAND SCREENS

  Safe

  At Risk

  N/A

• SIGHT GLASSED

  Safe

  At Risk

  N/A

• COMMENTS

  Yes

  No

  N/A

BASKETS

• NUMBER OF BASKETS ON SITE

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15

• DATE OF BASKET INSPECTION

  Date

• DATE ADDITIONAL BASKETS WILL BE SENT IN

  Date

• COMMENTS

  Yes

  No

  N/A

TOP DECK

• GENERAL CONDITION

  Safe

  At Risk

  N/A

• WALKWAYS CLEAR

  Safe

  At Risk

  N/A

• CLEANLINESS

  Safe

  At Risk

  N/A

• SAFETY RECOMMENDATIONS

  Yes

  No

  N/A

PRODUCTION DECK

• GENERAL CONDITION

  Safe

  At Risk

  N/A

• WALKWAYS CLEAR

  Yes

  No

  N/A

• CLEANLINESS

  Yes

  No

  N/A

• SAFETY RECOMMENDATIONS

  Yes

  No

  N/A

CELLAR DECK

• GENERAL CONDITION

  Safe

  At Risk

  N/A

• WALKWAYS CLEAR

  Safe

  At Risk

  N/A

• CLEANLINESS

  Safe

  At Risk

  N/A

• SAFETY RECOMMENDATIONS

  Yes

  No

  N/A

SLIPS, TRIPS, AND FALL PROTECTION

• Are floors in good repair?

  Yes

  No

  N/A

• Are floors free of rough or slippery surfaces?

  Yes

  No

  N/A

• Are non-skid materials used in high-traffic areas where floor may become wet?

  Yes

  No

  N/A

• Are carpets free of humps, curled edges, or tears?

  Yes

  No

  N/A

• Is sand/salt immediately spread on icy spots?

  Yes

  No

  N/A

• Are toe boards at least 4 inches high?

  Yes

  No

  N/A

• Are fixed stairways a minimum width of 22 inches?

  Yes

  No

  N/A

• Are stair railings firmly in place and solidly anchored?

  Yes

  No

  N/A

• Are stair treads serviceable and undamaged?

  Yes

  No

  N/A

• Is lighting adequate on stairways?

  Yes

  No

  N/A

• Is emergency lighting in place and working on stairways?

  Yes

  No

  N/A

• Are items removed from stairs?

  Yes

  No

  N/A

• Are ladders strong enough for the intended use?

  Yes

  No

  N/A

• Do ladders have non-slip safety feet?

  Yes

  No

  N/A

• Are ladders long enough and appropriate for the job?

  Yes

  No

  N/A

• Are ladders properly extended and tied at top of structure for security?

  Yes

  No

  N/A

• Are defective or unsafe ladders removed from service?

  Yes

  No

  N/A

• Are rungs free of grease and oil?

  Yes

  No

  N/A

• Is only only one person permitted on ladder at one time?

  Yes

  No

  N/A

• Are ladders, not boxes or chairs, used to reach high places?

  Yes

  No

  N/A

• Are workers prohibited from standing no more than three runs from the top of the ladder?

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

CONFINED SPACE ENTRY

• JSA

  Yes

  No

  N/A

• RESCUE PLAN

  Yes

  No

  N/A

• GAS METER 4 GAS

  Yes

  No

  N/A

• SAFETY EQUIPMENT (Tri-pod, Radios, Air Blower, Air Packs)

  Yes

  No

  N/A

• HARNESS AND LANYARDS (Inspection Tags, D Rings, Cleanliness)

  Yes

  No

  N/A

• BARRIERS (Open holes taped off, Work site preparation area taped off, Hoses taped)

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

TASK SITE CONTROL MEASURES

• Job site work area is clear of trip hazards.

  Yes

  No

  N/A

• Barriers are in place and area is secure from non-essential personnel.

  Yes

  No

  N/A

• All members are wearing proper PPE applicable to the task.

  Yes

  No

  N/A

• All personnel lifting equipment inspection tags are visible for inspection.

  Yes

  No

  N/A

• Members working together with good communication.

  Yes

  No

  N/A

• Members are following pre-task TBRA discussion during the job.

  Yes

  No

  N/A

• All necessary paperwork (if applicable) is available and completely filled out (TBRA, PTW, etc.)

  Yes

  No

  N/A

• The job has been broken down into manageable steps. (4 Pt. Check)

  Yes

  No

  N/A

• All members can explain the job steps.

  Yes

  No

  N/A

• All members know the hazards for each job step. (4 Pt. Check)

  Yes

  No

  N/A

• The hazards for the job have been reasonably identified. (4 Pt. Check)

  Yes

  No

  N/A

• Each hazard has been reduced to "As Low As Reasonably Practicable"

  Yes

  No

  N/A

• COMMENTS: SAFE

  Yes

  No

  N/A

• COMMENTS: AT-RISK

  Yes

  No

  N/A

• SAFETY RECOMMENDATIONS

  Yes

  No

  N/A

PROCEDURAL MANAGEMENT

• JOB PREPARATION FACTORS:

• 1. Hazard awareness training complete

  Yes

  No

  N/A

• 2. Knowledge of task

  Yes

  No

  N/A

• 3. Communication Flow

  Yes

  No

  N/A

• 4. Short service employee (Mentor in place)

  Yes

  No

  N/A

• BODY POSITION

• 1. Hand placement

  Safe

  At Risk

  N/A

• 2. Body positioning

  Safe

  At Risk

  N/A

• 3. Footing around work area

  Safe

  At Risk

  N/A

• 4. Lifting equipment

  Safe

  At Risk

  N/A

• 5. Moving equipment

  Safe

  At Risk

  N/A

• 6. Moving around loads

  Safe

  At Risk

  N/A

• PAPERWORK

• 1. Job Safety Analysis (JSA)

  Yes

  No

  N/A

• 2. NACHER JSA Job Procedures (copy)

  Yes

  No

  N/A

• 3. Client Permit to Work (copy at each entry)

  Yes

  No

  N/A

• 4. Foreman Job Site Audit Form

  Yes

  No

  N/A

• 5. Safety Observation Cards

  Yes

  No

  N/A

• REQUIRED RISK MANAGEMENT TOOLS

• 1. 4 Pt. Check Wristband

  Yes

  No

  N/A

• 2. Stop Work Authority Card

  Yes

  No

  N/A

• 3. Hard Hat Chin Straps (If applicable)

  Yes

  No

  N/A

• 4. Electronic HSE Manual (Project Manager)

  Yes

  No

  N/A

WELDING AND CUTTING EQUIPMENT

• Are hoses tested periodically for leaks, damage, and loose connections?

  Yes

  No

  N/A

• Are hoses free of oil and grease?

  Yes

  No

  N/A

• Are arc welding machines grounded before each use?

  Yes

  No

  N/A

• Are manufacturers' safety labels and instructions in place on equipment?

  Yes

  No

  N/A

• Do welders wear long sleeve cotton shirts, free of oil and grease?

  Yes

  No

  N/A

• Are correct goggles and eyeshades available and in use on welding/cutting jobs?

  Yes

  No

  N/A

• Are helmets and leather aprons available and in use on welding and cutting jobs?

  Yes

  No

  N/A

• Are gloves and leggings available for use on welding/cutting jobs?

  Yes

  No

  N/A

• Do portable tinted screens or curtains surround welding/cutting areas?

  Yes

  No

  N/A

• Are flammables removed from the welding/cutting area?

  Yes

  No

  N/A

• Are fire extinguishers available and carried to welding/cutting site before job starts?

  Yes

  No

  N/A

• Are welding/cutting areas well ventilated?

  Yes

  No

  N/A

• Are metal fume respirators available to welders?

  Yes

  No

  N/A

• Are Hot Work Permits available?

  Yes

  No

  N/A

• Are only trained personnel permitted to operate welding and cutting equipment?

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

PORTABLE HAND TOOLS

• Are portable hand and power tools inspected before use for defects?

  Yes

  No

  N/A

• Are extension cords underwriters laboratory listed and adequate for their intended use?

  Yes

  No

  N/A

• Are tools and equipment used as specified by the manufacturer and prohibited from being altered?

  Yes

  No

  N/A

• Do operators for portable hand and power tools have safety glasses available and use them?

  Yes

  No

  N/A

• Are extension cords fastened in ways that would prevent damage to insulation?

  Yes

  No

  N/A

• Are attached plugs and receptacles prohibited from being altered to prevent grounding?

  Yes

  No

  N/A

• Is defective or damaged equipment removed from service?

  Yes

  No

  N/A

• Are protective barriers/walls in place around power tool areas to protect other employees?

  Yes

  No

  N/A

• Are extension cords prohibited from being used to raise or lower equipment?

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

• IMMEDIATE ATTENTION

  Yes

  No

  N/A

• RECOMMENDATIONS

  Yes

  No

  N/A

SIGNED

• HSE Field Auditor

  Sign

• Company Representative

  Sign

• NACHER Foreman

  Sign

INTERNAL CIRCULATION

• HSEQ MANAGER

  Sign

• VICE PRESIDENT

  Sign

• DIVISION MANAGER

  Sign