Checklist for Clean Water / Drainage System

LOGO / NAME OF SRF

Document Register Number
Date of Issue
Number of Issue

This form is a checklist for the control of the Clean Water Tank and related Drainage Pipe System.
The checks are carried out on a monthly basis and are more frequent during monsoon season. The
tank will be inspected annually or immediately in case of leakage.
Please fill in white cells.

Checklist for Clean Water Tank and related Drainage System

Name of Inspector in Block Letters:

Date of Check:

Current Tank Level:

Status of Tank Cleanliness □ □ Instruction: Cleaned on Date:

(visual) Clean Dirty
Signature:

Status of Tank Cleanliness* □ □ Instruction: Cleaned on Date:

(measurement by gas below above
meter) Limits Limits Signature:

Status of Drainage □ □ Instruction: Cleaned on Date:

Cleanliness Clean Dirty
Signature:

Status of Structural □ □ Instruction: Cleaned on Date:

Condition Tight Leakage
(Total Tank Inspection) Signature:

NOTES
*Measurements from calibrated gas meter
Parameter Reading: Target

O2 [%] 21%

LEL [%] <1%

Signatures

Task completed □ Yes □ No**

Inspector (Signature)

Supervisor / HSE Manager (Signature)

** New form has to be filled in.

COPY OF THE DOCUMENT MUST BE RETAINED FOR MIN. 3 MONTHS AFTER LAST CHECK.