APPENDIX “6”

SIGN DESIGN & FABRICATION, INC. Machinery Tag-Out Program Inspection Form

This form will be used when inspecting the Tag-Out/ Lock Out Procedure Inspector’s Name _______________________________ Date __________________ MACHINERY / EQUIPMENT INSPECTED COMMENTS

1. ______________________________ ____________________________.
2. ______________________________ ____________________________.
3. ______________________________ ____________________________.
4. ______________________________ ____________________________.
5. ______________________________ ____________________________.

I hereby certify that I have inspected the Lock Out/Tag-Out procedure for the above listed equipment, have interviewed operators of such equipment and determined that compliance with SIGN DESIGN & FABRICATION, INC. Lock Out/Tag-Out procedure is satisfactory.

Inspectors Signature Date

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