Job or Project #

ABInBev xxxxxxx Brewery

ESM - Abandoned Electrical Equipment Certificate
VPO.SAFE.3.1.04.09 Electrical Safety Management Abandoned
Electrical Equipment

Complete this form to document that the abandoned electrical equipment has been disconnected from all
electrical power and cleared of any harmful components. Dismantling (or similar activities) of abandoned
equipment can begin only after the completion of this Certificate.
xxxxx Brewery
Address of plant
Scope of Work:

Document the completion of the following steps.

1. Abandoned equipment is completely electrically disconnected from the
existing operational system.  Yes  No  N/A

2. Abandoned equipment is completely mechanically disconnected from the

existing operational system.  Yes  No  N/A

3. If the equipment is oil filled, it has been certified PCB free.

 Yes  No  N/A
(Attach PCB Free Certification)
4. If the equipment cannot be certified PCB free, have special disposal
 Yes  No  N/A
methods been implemented. (Attach documentation)
Abandoned Electrical Equipment Certificate Endorsement - Signature indicates that all of the required steps have
been addressed. At least one (1) of the following must sign the document. File the completed Certificate with the
plant ESM documentation.

Facility Engineer or Date

CAPEX Team Member

Resident Engineer Date

Facility ESM Coordinator Date

Form Revision Date 01/09/2018 Abandoned Electrical Equipment – Certificate Page 1 of 1