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Sierra Chemical Co. <br /> ACarusCompany Work Order Request Form (electronicversion) <br /> PREVENTIVE (PM): Y ❑ N ® PSM: Y ❑ N ® W/O NO.: ST-2016-137 <br /> Requested By: Alex Revnon Date: 4/11/2016 <br /> Priority: 1❑ 20 3❑ 4M 5❑ (Check One) Rating scale from 1- Routine Maintenance to 5-Emergency <br /> Equipment ID: <br /> N/A <br /> Description: <br /> Rain water retention pond <br /> Work Requested: <br /> Sample the rain water retention area for pH. Make sure use the electronic hand held meter(not strips) and to take <br /> photographic evidence. <br /> Engineering/Safety Review: <br /> Prior To Commencing Work The Following Condition Must Be Met <br /> Safe Work Permit(Confined Space, Lockout/Tagout, Hot Work, and/or Fall Protection): N/A <br /> Personal Protective Equipment (PPE) Requirements: Standard <br /> Rubber boots <br /> Other: Potential for muddy conditions; be mindful of footing. <br /> Reviewed By: Alex Re non 4/11/2016 <br /> Maintenance/Contractor Work: <br /> Work Performed: <br /> Four samples taken from the perimeter of the pond: further write up found in inspection/test result section. <br /> Parts/Materials Used: <br /> n/a <br /> Work Completed By: Alex Re non 4/12/2016 <br /> _ APPROVALS <br /> Facili MarlNIer Maint� Compliance <br /> Revision 7/13/15 Form WOR.16.E <br />