(Check Sheet For Fire Extinguisher-Fortnightly-18 days. Date & Time: (CHECK ITEMS. DESCRIPTION REMARKS |Conuition ofthe extinguisher (Clean and |rigy) 2 [Physical appearance for corrosion. 3 {safety pinin position |Conaition of discharge nozzoletany lblockagesdamage) 5 |Condition of hose(any leakage/broken) |Woight ofthe extinguisher(Should be 6 |match with actual weight written in the Jbody) 7 |avaitabitty of visual board. [an the inaicator gages(where fitted)in |aroon segment(not to be red) [Extinguisher is not expired or refilled lbetore refed date [Checked by contractor safety officer: [Witnessed byProject z Project No. Client Location: Declaration for Safe Work At Height Date: ‘Location: ‘Contractor Name: Work Description: PTWNo.: SN DESCRIPTION YES | NO REMARKS 1 | Centtied Scaffolding Platform ‘ provided work 2 | certified cherry picker / scissor lft/ man-basket Provided to access work area. 3 | Ladder isin good condition. Ladder should be placed at 65-75 degree angle (1:4 ratio) & secured propery. 4 | Safety harness with double ; lanyard must be worn. Maintain 100% tie off all the time at anchoring point/ life line 5 | Tagline available to take the materials on to the _platfrms é "Name of Persons Involved: Signature Name of Persons involved: | signature i zs z 3B 3 a. 4 A 10. e 5. i 6 2. Declaration By Contractor Thereby declare that, Ihave explained work at height safety Supervisor precautions to my team members. | am solemnly responsible for safety of my team members and any incident if ever occurs. Supervisor Name | Mr. Day/Date —_|Mon [Tue | Wed. Sat. | Sun. Signature ‘Attach copy of declarationProject ‘Client Location Project No. Power Distribution Board Inspection Checklist- Monthly Date & Time of Inspecti In Site Location : indicator to be available Equipment No: SN Description Photos Yes |No | Remarks 1 Plug-Socket should be Industrial type. 2 Color coding to be followed (RYB) for all cables'wires and 3 Separate RCCB with tripping current of 30 Mil Amp & in ‘working condition. Name 4 Safety sign of High Voltage Or danger symbol 5 Power on and off switch gear with good condition. 6 Firm Base & Easily accessible panel. 7 Earthing System of MDB / DB panel with Std, earthling pit. 8 Presence of rubber mat in front of the D.B (Operator standing Location) 9 Fire Fighting arrangement. Signature Signature Verified by Contractor Safety Representative