DETAILED CHECKLIST
Facility Name:
Location: LSD
Operator or Manager:
Date:
Signature:
Job Title:
Review Questions
Date
Completed
Company:
Team Members
Signatures
Project Completion:
1.
2.
3.
4.
5.
6.
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Page 1 of 3
Yes
Date
Completed
Team Members
Signatures
Date
Completed
Team Members
Signatures
No
N/A
Review Questions
Operating Procedures:
1.
2.
3.
4.
5.
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
6.
Yes
No
N/A
7.
Other
Yes
No
N/A
Page 2 of 3
Review Questions
Personnel Training:
1.
Date
Completed
Team Members
Signatures
Yes
No
N/A
3.
4.
Yes
Yes
Other:
Yes
No
N/A
No
N/A
No
N/A
Comments:
Retain this document for the life of the Facility. File with completed MOC package.
Operating Department Manager/Supervisor
Name:
Title:
Signature
Date:
Page 3 of 3