Test Form 2

FIRE STATION

Quarterly Facility Safety Inspection Form

Date

Facility

Person Conducting Inspection

Employee #

GENERAL SAFETY

Safety programs available for employee review

-- Recommended Action

Safety posters are displayed as required

-- Recommended Action

Hazard assessment process is being done as required

-- Recommended Action

WORK AREA

Worksites are kept clean and orderly

-- Recommended Action

Combustible waste is removed from premises daily

-- Recommended Action

Spills and leaks are cleaned up immediately

-- Recommended Action

Floor surfaces are in good repair

-- Recommended Action

Heavy items stored low, light items stored high

-- Recommended Action

Ladders are available and in good condition

-- Recommended Action

Shelves and cabinets secured to prevent toppling

-- Recommended Action

Hanging items, appliance equipment secure in place

-- Recommended Action

Lighting is adequate for job condition

-- Recommended Action

Trip hazards are clearly marked (steps and stairs)

-- Recommended Action

Plumbing fixtures are working properly, no leaks

-- Recommended Action

Toilets and washing facilities kept sanitary

-- Recommended Action

Furniture is kept in good repair

-- Recommended Action

Windows & glass doors are in good order, no cracks

-- Recommended Action

Doors between apparatus room and other areas closed

-- Recommended Action

Eating and drinking are done in appropriate areas

-- Recommended Action

EQUIPMENT/TOOLS

Power equipment is in good working condition

-- Recommended Action

Tools are in good condition & replaced when damaged

-- Recommended Action

Adequate clearance is maintained near machinery

-- Recommended Action

Employee protective equipment is available and used

-- Recommended Action

Emergency eye wash/showers operate properly

-- Recommended Action

Protective machine guards are in place

-- Recommended Action

Only authorized personnel permitted in work area

-- Recommended Action

Lift truck policies are enforced

-- Recommended Action

EXITING

-- Recommended Action

Hallways, corridors & exits are clear of obstacles

-- Recommended Action

All exit door hardware is operable

-- Recommended Action

Emergency lighting is in working order

-- Recommended Action

FIRE PROTECTION

Portable fire extinguishers are available & serviced

-- Recommended Action

No smoking policies are enforced

-- Recommended Action

Test smoke detectors; replace battery Jan & July

-- Recommended Action

Combustible storage kept away from ignition sources

-- Recommended Action

Storage is kept below 24" of ceiling, no sprinklers

-- Recommended Action

Storage is kept 18" below sprinkler heads

-- Recommended Action

Sprinkler heads not obstructed or damaged

-- Recommended Action

Sprinkler heads and wrench are available

-- Recommended Action

Sprinkler system valves in “OPEN” position

-- Recommended Action

30" clearance of combustibles from heating equipment

-- Recommended Action

Sprinkler system 5 yr. service completed/tagged

-- Recommended Action

Hoods above cooking equip are in good order/clean

-- Recommended Action

Address numbering is visible from the street

-- Recommended Action

Fire lanes are kept clear

-- Recommended Action

Emergency fuel shutoffs are clearly marked & tested

-- Recommended Action

Welding/flame cutting policies are enforced

-- Recommended Action

ELECTRICAL

-- Recommended Action

Electrical fixtures and wiring are in good repair

-- Recommended Action

Only approved extension cords are in use

-- Recommended Action

30" clearance in front of electrical panel

-- Recommended Action

Ground fault interrupters near water sources 0 0 0 are in good working order

-- Recommended Action

HAZARDOUS MATERIALS

Oily rags are kept in approved metal container

-- Recommended Action

Storage of flammables are in approved locations

-- Recommended Action

Hazardous materials are stored safely

-- Recommended Action

All containers are properly labeled

-- Recommended Action

Biohazards are properly disposed of

-- Recommended Action

MISCELLANEOUS

H.V.A.C. equipment in good working order

-- Recommended Action

Pits and floor openings are covered/protected

-- Recommended Action

Overhead doors are in good working order

-- Recommended Action

Air compressor unit in good working order/inspected

-- Recommended Action

Compressed gas cylinders are secured

-- Recommended Action

Exhaust removal systems work properly

-- Recommended Action

Gates and fence components securely standing

-- Recommended Action

OTHER

DATE AND SIGN

Name of Inspector

Date

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