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LOCKOUT TAGOUT POLICY AND PROCEDURES <br />SAMPLE LOCKOUT/TAGOUT EQUIPMENT ISOLATION FORM <br />Lockout/Tagout <br />Equipment Isolation Procedure Form <br />Department: Laundry Supervisor: Mr. Slate <br />Date: October 8, 2008 Equipment: Dryer -Make and Model <br />Energy Sources and Location: <br />Natural Gas Valve: Behind dryer <br />240 VAC, 3 -Phase: Breaker Panel "C" located in Soiled Utility, breaker #23 <br />Type of lock or energy control device: Valve lock and circuit breaker lock. <br />Authorized employee(s): Fred Flintstone <br />Affected employee(s): Laundry Personnel <br />Sequence of events for lockout/tagout: <br />1. Notify affected employee(s). <br />2. Determine the types of energy and how to control them. <br />3. If equipment is running, shut it down, following normal procedures. <br />4. Locate natural gas valve; shut off and lock and tag -out. <br />5. Locate electrical disconnect, shut off and lock and tag -out. <br />6. Verify the equipment is de -energized by pressing the start button and checking pilot light. <br />7. Perform service and/or repair. <br />8. Inspect equipment and area around equipment before re -energizing. <br />9. Make sure equipment is in the "off' position. <br />10. Notify affected associate(s) before removing locks and tags. <br />11. Remove locks and tags and re-energize equipment by normal start-up procedure. <br />Golden Living LOCKOUT/TAGOUT Page 7 of 10 <br />