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This check sheet is to be completed by the Operator & the Subject Matter Supervisor in charge of the new technology
to be deployed. A copy of this form is to be submitted for site EHSQ when requesting a Permit to Work. The original
form is to be kept on location along with copies of all test certificates and supporting documents.
Company: Date:
Location: Operation:
ITEM Certification Remarks
Technology Checked Document No.
Outline of the goal OK
Functional Specification OK
Layout drawings with position numbers, part list and materials OK
identification
Materials specifications and performance in the intended operating OK
conditions. Validate if service experience in these conditions exists
Quality Assurance/Quality Control Plan OK
NOTE: Certification should cover load testing, pressure testing and NDT testing as appropriate for the equipment.
All certification must be traceable to the unique serial number on the piece of equipment.
Operator’s Name: Operator’s
Signature/Date:
Supervisor: Supv.
Signature/Date: