WORKPLACE EQUIPMENT INSPECTION RECORD Inspecting Inspection Date Department Responsible Inspection Time 24hr Inspected By by TPenney

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									WORKPLACE/EQUIPMENT INSPECTION RECORD
Inspecting: _____________________ Inspection Date: _____________ Department Responsible: _________________ Inspection Time: 24hr.__________ Inspected By: ______________________ Action/Recommendation Date Due: _______________ Completed Date: ___________________

Person Responsible for Action/ Recommendation: ______________________________ Home Office ____ Yard ____ Location : ____________________________________ Dangerous Goods Y/N ___

Supervisor: ________________________

WHMIS Y/N ___

ITEM & LOCATION

HAZARDS OBSERVED

HAZARD CLASS **

REPEAT ITEM Y/N

RECOMMENDED ACTION

ACTION TAKEN/DATE

BY WHOM

HAZARDS CLASSIFICATION "A" HAZARD ** A condition or practice likely to cause permanent disability, loss of life, or extensive property damage. "B" HAZARD ** A condition or practice likely to cause temporary disability or disruptive property damage "C" HAZARD ** A condition or practice likely to cause minor injury or minor property damage. COPIES SENT TO (for action): ____________________ Date: ____________

Signature: _____________________

Print Name: ____________________

THIS DOCUMENT TO BE DISTRIBUTED TO ALL AFFECTED WORKERS AND POSTED IN A CONSPICUOUS PLACE


								
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