UNSAFE ACT / NEAR MISS / INCIDENT/ ACCIDENT

REPORT FORM

1. Reported By :

Name : ______________________________ Sign ________________

Designation : ________________

2. Details of the concern :

Location : __________________

Date / Time : _________________

3. Type of concern :

Near Miss Unsafe Act Unsafe Condition

Accident Incident

4. Treatment :

Nil First Aid Hospital

5. Description of what happened :

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

6. Action taken :

Authorised Sign
 Certificate No. :CEC/HP/12/2023

E Creative Engineers & Consultants

Flat No. 20, Block No. B-4, Jamuna Apartment, Kharar-140301, Distt. Mohali (Pb.)
M:+91 8198042525, E-mail:skgupta.creative@gmail.com, Website:www.creativeengineers.org.in
COMPETENT PERSONS - CHARTERED ENGINEERS - AUDITORS – GOVT. APPROVED VALUERS
Approved Competent Person by Chief Inspector of Factories of Punjab, Haryana, Himachal Pradesh & Rajasthan
For Safety Testing & Certification of Pressure Vessels/ Plant, Lifting Machines/Tools/Tackles, Lifts/Hoists, Dangerous Machinery, Dust
Extraction system under section 28, 29, 21(2), 31 & 67 of Factories Act.
Form No.8 (Prescribed under Rule 61)
Report of Examination of Pressure Vessel/ Plant

CERTIFICATE OF TESTING OF PRESSURE SAFETY RELIEF VALVE

Date :
Station Manager
Hindustan Petroleum Corp. Ltd.
S.G.R.D.J International Airport
Amritsar – 143101, Punjab

Here by certify that the following Pressure Safety Relief valves have been tested as per
the Particulars below and found fit for uses.

S.No Details of Safety Valve Fitted on Pressure at which Observations

valve released /
opened (PSI)

1. PRV No. SB-62/01 R67 148 PSI Working

Satisfactory
2. PRV No. SB-62/01 R67 148 PSI Working
Satisfactory
3. PRV No. SB-62/01 R67 148 PSI Working
Satisfactory
4. PRV No. SB-62/01 R67 148 PSI Working
Satisfactory
5. PRV No. SB-62/01 R67 148 PSI Working
Satisfactory
6. PRV No. SB-62/01 R67 148 PSI Working
Satisfactory

S.K. GUPTA
S K GUPTA Competent Person & Chartered Engineer
Jamuna Apartments
Kharar-140301
Mohali (Pb)