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SAFETYAPPROVALFORM AND CHECKLIST FOR MACHINERIES &EQUIPMENTS
Mobile Crane, Wheel Loader (Shovel), Telehandler (Boom Lobdell), Skid Steer Loader (Bobcat),
Backhoe, Excavator, Dump Truck, Bulldozer, Water Tanker etc.….)
Page 1 of 3 Form # HSEQ-SACME (Rev 1 – Mar 23)
DATE:……/……/2017
PROJECT :………………………………...... PMV:………………………………
DESCRIPTION :………………………………...... Model:…………………………….
PLANT #/Reg. :………………………………………… CAPACITY:………………………
SUPPLIER :………………………………...... CONTACT#:………………………
OPERTOR NAME:……………………………………… MB No:…………………………….
MOBILE NO : ……………………………………….. LICENSE No:………………………
REMARKS BY SAFETY ENGINEER:
REASONS FOR NOT APPROVED:
1. . .....................................................................................................................................................................................
2. . .....................................................................................................................................................................................
3. . .....................................................................................................................................................................................
4. . .....................................................................................................................................................................................
5. . .....................................................................................................................................................................................
DATE:…/……/2017
SIGNATURE OF SAFETY ENG
……………………………………………......
NAME.:……………………………………….
MB NO:……………………………………….
This form should be submitted to transport department, after checking the Machineries &
equipment’s.
APPROVED NOT APPROVED
SAFETYAPPROVALFORM AND CHECKLIST FOR MACHINERIES &EQUIPMENTS
Mobile Crane, Wheel Loader (Shovel), Telehandler (Boom Lobdell), Skid Steer Loader (Bobcat),
Backhoe, Excavator, Dump Truck, Bulldozer, Water Tanker etc.….)
Page 2 of 3 Form # HSEQ-SACME (Rev 1 – Mar 23)
Equipment Details:
Reg. No: …………………………….
Sl.
No.
Description Yes No N/A Remarks
1 Valid Vehicle Registration (Mulkhiya)
2 Valid Operator driving license
3 Valid third party certification (Machinery / Equipment)
4 Valid third party certification (Lifting Tackles-Mobile crane)
5 Valid third party certification (operator/driver)
6 Physical Condition
A. Tires
B. Brakes (Including hand brakes)
C. Lights- brake, reverse, Indicator
D. Electrical connections
E. Oil leakage of any sort-hydraulic, brake, lubricant etc..
F. Operator Cabin-Glasses clear from obstruction
G. Joint pins, bolt & nuts for physical connections
H. Rear view mirror (rear convex mirror for telehandlers)
I. Doors
J. Horn / Siren
K. Safety seat belt
L. Revolving light
M. Reverse alarm - audible around 5 Mtr. radius
N. Fire extinguisher- operational
SAFETYAPPROVALFORM AND CHECKLIST FOR MACHINERIES &EQUIPMENTS
Mobile Crane, Wheel Loader (Shovel), Telehandler (Boom Lobdell), Skid Steer Loader (Bobcat),
Backhoe, Excavator, Dump Truck, Bulldozer, Water Tanker etc.….)
Page 3 of 3 Form # HSEQ-SACME (Rev 1 – Mar 23)
O. Load chart (for telehandlers & Mobile crane)
P. Boom radius indicator (for telehandlers & Mobile crane)
Q. Boom angle indicator (for telehandlers & Mobile crane)
R. Out rigger - Fully extendable condition (for telehandlers
& Mobile crane)
S. Safe working limit : Green-under SWL, Orange-
Reached SWL, Red-Exceeded SWL (for telehandlers &
Mobile crane)
T. Anti-two block (for mobile crane)
U. Limit switch (for mobile crane)
V. Control panel in the operators cabin (for mobile crane)
7 Civil Defense Fitness Certificate (for Diesel tankers)
8 Daily check list for the machineries/Equipment
9 Others
Status :
Reason(s) for not approval: ..........................................................................................................
…... ................................................................................................................................................
Checked by :
Signature:
Date :
Time:
APPROVED NOT APPROVED

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SAFETY APPROVAL FORM AND CHECKLIST FOR MACHINERIES & EQUIPMENTS rev 1.docx

  • 1. SAFETYAPPROVALFORM AND CHECKLIST FOR MACHINERIES &EQUIPMENTS Mobile Crane, Wheel Loader (Shovel), Telehandler (Boom Lobdell), Skid Steer Loader (Bobcat), Backhoe, Excavator, Dump Truck, Bulldozer, Water Tanker etc.….) Page 1 of 3 Form # HSEQ-SACME (Rev 1 – Mar 23) DATE:……/……/2017 PROJECT :………………………………...... PMV:……………………………… DESCRIPTION :………………………………...... Model:……………………………. PLANT #/Reg. :………………………………………… CAPACITY:……………………… SUPPLIER :………………………………...... CONTACT#:……………………… OPERTOR NAME:……………………………………… MB No:……………………………. MOBILE NO : ……………………………………….. LICENSE No:……………………… REMARKS BY SAFETY ENGINEER: REASONS FOR NOT APPROVED: 1. . ..................................................................................................................................................................................... 2. . ..................................................................................................................................................................................... 3. . ..................................................................................................................................................................................... 4. . ..................................................................................................................................................................................... 5. . ..................................................................................................................................................................................... DATE:…/……/2017 SIGNATURE OF SAFETY ENG ……………………………………………...... NAME.:………………………………………. MB NO:………………………………………. This form should be submitted to transport department, after checking the Machineries & equipment’s. APPROVED NOT APPROVED
  • 2. SAFETYAPPROVALFORM AND CHECKLIST FOR MACHINERIES &EQUIPMENTS Mobile Crane, Wheel Loader (Shovel), Telehandler (Boom Lobdell), Skid Steer Loader (Bobcat), Backhoe, Excavator, Dump Truck, Bulldozer, Water Tanker etc.….) Page 2 of 3 Form # HSEQ-SACME (Rev 1 – Mar 23) Equipment Details: Reg. No: ……………………………. Sl. No. Description Yes No N/A Remarks 1 Valid Vehicle Registration (Mulkhiya) 2 Valid Operator driving license 3 Valid third party certification (Machinery / Equipment) 4 Valid third party certification (Lifting Tackles-Mobile crane) 5 Valid third party certification (operator/driver) 6 Physical Condition A. Tires B. Brakes (Including hand brakes) C. Lights- brake, reverse, Indicator D. Electrical connections E. Oil leakage of any sort-hydraulic, brake, lubricant etc.. F. Operator Cabin-Glasses clear from obstruction G. Joint pins, bolt & nuts for physical connections H. Rear view mirror (rear convex mirror for telehandlers) I. Doors J. Horn / Siren K. Safety seat belt L. Revolving light M. Reverse alarm - audible around 5 Mtr. radius N. Fire extinguisher- operational
  • 3. SAFETYAPPROVALFORM AND CHECKLIST FOR MACHINERIES &EQUIPMENTS Mobile Crane, Wheel Loader (Shovel), Telehandler (Boom Lobdell), Skid Steer Loader (Bobcat), Backhoe, Excavator, Dump Truck, Bulldozer, Water Tanker etc.….) Page 3 of 3 Form # HSEQ-SACME (Rev 1 – Mar 23) O. Load chart (for telehandlers & Mobile crane) P. Boom radius indicator (for telehandlers & Mobile crane) Q. Boom angle indicator (for telehandlers & Mobile crane) R. Out rigger - Fully extendable condition (for telehandlers & Mobile crane) S. Safe working limit : Green-under SWL, Orange- Reached SWL, Red-Exceeded SWL (for telehandlers & Mobile crane) T. Anti-two block (for mobile crane) U. Limit switch (for mobile crane) V. Control panel in the operators cabin (for mobile crane) 7 Civil Defense Fitness Certificate (for Diesel tankers) 8 Daily check list for the machineries/Equipment 9 Others Status : Reason(s) for not approval: .......................................................................................................... …... ................................................................................................................................................ Checked by : Signature: Date : Time: APPROVED NOT APPROVED