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JIFFY LUBE MONTHLY HSSE CHECKLIST Date: <br /> Store Number: 1478 Performed By: Peter Gaines <br /> Questions: Yes No N/A Questions: Yes No N/A <br /> PERSONAL PROTECTIVE EQUIPMENT(PPE) Do light fixtures within 8 feet for floor have protective <br /> covers(plastic cover or bulb sleeves)for bulbs? <br /> Is PPE available for employees(shoes,gloves, Are electrical plugs and cords,including extension <br /> burn sleeves,glasses,face shields, bump caps, cords, in good condition? <br /> goggles and aprons)? No cuts,breaks,tears,frays or tape applied) <br /> Ask an employee to demonstrate the use of Are extension cords used only for temporary purposes? <br /> his/her PPE to ensure that PPE being properly (Fixed electrical devices should be plugged directly into <br /> used/worn outlet without extension cord) <br /> Have all new employees completed the annual Are electric cords kept off walking and working <br /> PPE certification(Safety Tab A)? surfaces to prevent electric shock or tripping?(Vacuum <br /> cords in lower bay should not touch floor <br /> PIT OPENINGS WASTE HANDLING <br /> Are protective covers(bay nets and/or grates)and Are used antifreeze and mop water both stored in their <br /> toe boards present, in good condition, and own containers?(Should not be commingled together) <br /> properly used? <br /> Are bay"Caution,Open Floor"signs/banners Are oily rags stored in a metal can with a tight closing <br /> present? lid? <br /> WALKING AND WORKING SURFACES Are waste manifest legible,descriptive and signed? <br /> Are all walking and working surfaces(steps and Are completed manifests or trip tickets kept on file for <br /> flooring)clean and dry? all waste streams?(MA only—copy 3&6 kept on file <br /> for 3 years, photocopy of copy 6 mailed to Houston, <br /> photocopy of copy 3 mailed to MDEP <br /> Do all catwalks that are 4 feet or more above the Are all used oil filters either punctured or crushed? <br /> round have railings on all sides? <br /> Do all catwalk steps with more than four risers(3 Are used fuel filters stored in an approved container in <br /> steps)have handrails? the upper bay? <br /> Are safety chains in place in the upper bay when Are all filters and quart containers fully drained prior to <br /> stairs are not in use? disposal? <br /> Are all exits labeled and exit paths free of ANTIFREEZE REPLACEMENT MACHINES <br /> obstructions? <br /> Are handrails in good condition and painted Is a drip pan available and in good condition when <br /> yellow? performing outdoor services? <br /> Are handrail signs posted in plain view? Does the machine have the proper label for handling <br /> spilled antifreeze? <br /> Are ladders(including step stools)in good FOUNDATION SUMPS <br /> structural condition and have rubber feet? <br /> Are steps in upper and lower bays in good Are employees aware of where sumps discharge <br /> structural condition? (sanitary sewer or storm sewer <br /> Are overhead obstructions painted yellow?(low- Is sump discharge path identified on SPCC drainage <br /> hanging i in in walkways) diagram?(To sanitary or storm sewer <br /> Are step-ups painted yellow to show change in Is discharge sampling done, if needed? <br /> elevation?(paint 2"yellow on rise and tread of <br /> steps from bay to lounge,office and utility room <br /> Are all hoses picked up off of the floor?(vacuum Is there a cover and lock over the sump? <br /> hoses, product hoses,etc.) <br /> Is the work area free of sharp objects and Is the sump berm intact on all sides? <br /> surfaces? <br /> ELECTRICAL OTHER SPILL-RELATED ISSUES <br /> Are all circuit breakers and separate breaker Is there a spill kit on hand and accessible? <br /> boxes labeled to identify the equipment they <br /> control? <br /> Are all open slots in panel covered? Have used spill kit materials been removed by the <br /> waste hauler? <br /> Is there 30"of clearance in front of the breaker Is the spill kit fully stocked? <br /> box? <br /> Are electrical switches and/or outlets free from any Are the overfill and remote fill catchments free of oil <br /> obstructions? and debris? <br /> Do all electrical outlets and switches have covers EXIT SIGNS <br /> and are away from sources of water or other <br /> fluids? <br /> Are all electrical outlets free of exposed wires? Do all exterior exits have a lighted/luminous exit sign? <br /> Are smoke detectors operational? Are all bulbs in the exit signs and emergency lights <br /> working? <br /> Do all electrical cords have ground prongs? Do all lighted exit signs have a working battery back-up? <br /> All Jiffy Lube Monthly HSSE Checklist deficiencies must be corrected. <br /> I have reviewed each item of this checklist,and to the best of my knowledge,the answers provided accurately describe the conditions of this <br /> location. <br /> Signature: DATE <br />