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OSPS►�Mffi�e/SygtemUUw►g�ade T <br /> WESTERN PUMP i <br /> Operation Date <br /> Identify hazards in work area: <br /> Check Method of fall prevention/protection to be used: ❑ Standard Guardrail (top, mid and toe-board) ❑ Horizontal lifeline <br /> ❑ Anchorage point of 50001b load/person ❑ Vertical lifeline <br /> ❑ Boom lift (designated operator required) ❑ Retractable <br /> Other (Speci ) <br /> Check equipment to be used: ❑ Full body harness ❑ Rope/Cable grab <br /> Positioning lanyard Retractable Lanyard <br /> Describe procedure for assembly, maintenance, inspection and disassembly of system : <br /> Describe procedure for handling and securing tools, equipment and overhead protection for work areas below: (ex: toe boards, tool lanyards, etc.) <br /> Describe method for prompt, safe retrieval: <br /> Sketch of system : Use back of page if necessary. <br /> - I certify that I understand the hazards of this operation and have received necessary training associated with this operation. <br /> Name/ Date Signature Name/ Date Signature Reviewed By/ Date Signature <br /> Page 4 of 4 <br />