Pumping Equipment Safety Form
Please complete all sections to ensure the safe operation and inspection of pumping equipment.
Equipment ID or Serial Number
*
Inspection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector Name
*
First Name
Last Name
Location of Equipment
*
Overall Equipment Condition
*
Please Select
Excellent
Good
Fair
Poor
Are all safety devices (guards, alarms, interlocks) functional?
*
Yes
No
Not Applicable
Any visible leaks or spills detected?
*
No
Minor
Major
Potential hazards identified (select all that apply)
*
Electrical hazard
Mechanical hazard
Noise hazard
Slip/trip hazard
None
Other
Is maintenance required?
*
Yes
No
Describe any corrective actions taken or needed
Additional Safety Comments or Observations
Submit Safety Form
Should be Empty: