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WESTERN PUMP <br /> Petroleum & Lubrication Equipment Specialists <br /> LOCKOUT/TAGOUT PROCEDURE/CHECKLIST <br /> ENERGY SOURCE DETERMINATION <br /> DATE : CONDUCTED BY <br /> In order to determine all energy sources for each piece of equipment, all questions must beanswered. <br /> If the question does not apply, write N/A in the blank. Circle "yes" or " no" or fill in the blank. <br /> Location : W ork Cente r: <br /> Specific Service Order No, Assigned : <br /> List of authorized employees : <br /> 1. <br /> 2, <br /> 3 , <br /> 4, <br /> TRAINING NOTE. Aperson who locks out or tags out machines or equipment in order to perform servicing or maintenance on that machine or <br /> equipment. An affected employee becomes an authorized employee when that employee's duties include performing servicing or maintenance <br /> covered under this section. <br /> List of affected employees : <br /> 3235 "F" Street, San Diego , CA 92102-3315 * 619-239-9988 Fax 619-239-9925 <br /> www.westernpump. com <br /> California Contractor's License #673853 <br /> California Certified Small Business #33547 <br />