Trucker/Pressure Truck Observation Form

Trucker/Pressure Truck Observation Form
Your Name*

First NameLast Name
Date*

MonthDayYear
Date
Time of Observation*

:HourMinutesAM/PM Option
Type of Equipment*

Fluid HaulerVac/Combo TruckPressure TruckChemical/Propane Truck
Division*

AbandonmentCompletionsConstructionDrillingHSEOperationsWell Servicing
Operations Area*

Avon HillsColevilleCore NorthCore SouthDodslandCarrot CreekEdgertonHoosierMaintenanceMidstreamPlato
Completions Area*

AB - CompletionsSK - Completions
Abandonment Area*

AB - AbandonmentSK - Abandonment
Core South Runs*

Core South Chauvin Run #10Core South Chauvin Run #11Core South Chauvin Run #12Core South Chauvin Run #13
Core North Runs*

Core North Chauvin Run #00Core North Chauvin Run #01Core North Chauvin Run #02
Edgerton Runs*

Edgerton OperationsCzar Operations
Midstream Area*

Chauvin - Midstream
Well Servicing Area*

AB - Well ServicingSK - Well Servicing
Construction Area*

AB - ConstructionSK - Construction
Drilling Area*

AB - DrillingSK - Drilling
HSE Area*

AB - HSESK - HSE
Chauvin Area*

Chauvin - Operations
Maintenance Area*

Chauvin - MaintenanceSK - Operations - Maintenance - James Elliott
Carrot Creek Area*

AB - Operations
Avon Hill Runs*

Avon Hill - 2-15Avon Hill - 2-18Avon Hill - 5-26Avon Hill - 7-5Avon Hill - 8-13/14-27Avon Hill - 8-14Avon Hill - KerrobertAvon Hill - NWSUAvon Hill - Plenty 2-34Avon Hill - StranraerAvon Hill - Whiteside
Coleville Runs*

Coleville - 3-14Coleville - Run #1Coleville - Run #2Coleville - Run #3Coleville - Run #4 10-30Coleville - Run #5Coleville - Run #6
Dodsland Runs*

Dodsland - Run #1Dodsland - Run #2Dodsland - Run #3Dodsland - Run #4Dodsland - Run #5Dodsland - Run #6Dodsland - Run #7Dodsland - Run #8
Hoosier Runs*

Hoosier - Run #20Hoosier - Run #22Hoosier - Run #23Hoosier - Run #24Hoosier - Run #25Hoosier - Run #26Hoosier - Run #27Hoosier - Run #28Hoosier - Run #29Hoosier - Run #31Hoosier - Run #7Hoosier - Run #8
Plato Runs*

Plato - 11-7Plato - 13-12 BtyPlato - 13-12 WestPlato - 14-19Plato - Run #1 4-7Plato - Run #2Plato - Run #3Plato - Run #4Plato - Run #5 11-12Plato - Run #6 SUTPlato - Run #7 13-18Plato - Run #8 Elrose
Surface Location*
Information
Division vendor is working for*

Abandonment and ReclamationDrilling and CompletionsConstructionOperationsMidstream
Observed Worker Name*

First NameLast Name
Carrier Name*
Carrier Phone Number
Safety Contact Name

First NameLast Name
Safety Contact Email
example@example.com
Safety Contact Number

Area CodePhone Number
Comments
Truck Unit #*
Trailer Unit #(if no trailer put N/A)*
Can worker provide the following valid certificates?*

CSOFirst Aid (must be a minimum Level A & AED)H2STDGWHMIS
Can the worker provide a valid midstream orientation card? (if NO please have them leave the site or have a card issued to them)*

YesNo
Orientation Expiry Date*

MonthDayYear
Date
Is driver outside of truck when loading and unloading?*

YesNo
Why was driver not outside truck?*
Type of fluid being hauled*

Sour EmulsionSweet EmulsionSour Produced OilSweet Produced OilSour Produced WaterSweet Produced WaterFresh WaterOther
Can worker produce VALID Safe Work Permit, Valid Term Work Agreement or a Valid Midstream Orientation card (digital or paper copy)*

YesNo
Pic of SWP or TSWA

Take Picture / Upload File

Cancelof
Why does driver not have TSWA or Work Permit?*
Tank Test Markings Picture

Browse Files

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Identification Plate Picture

Browse Files

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Are proper placards in place (check truck ticket to ensure and enter picture, 3494 Heavy Oil and 1267 for Light Oil), is there a Inhalation Hazard placard present with the 3494 placard?*

YesNo
Why are proper placards not in place?*
Placard Picture

Take Picture / Upload File

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Are grounding cables being used?*

YesNo
Why are grounding cables not being used?*
Does trailer have overfill valve?*

YesNo
What level does it close at?*
Does driver know what the high Level alarm on trailer is set at? (enter level in comments)(N/A for float gauge on vac/combo and pressure trucks)*

YesNoN/A
High Level Comments
Is a grade 1 or 2 shear pin or bolt being used on PTO? Refer to bolt grade chart below if unsure of grade (enter size in comments) If truck is using hydraulic pump enter bypass pressure in comments*

YesNoHydraulic PumpCentrifugal PumpPressure Truck
Shear Pin Size*
Is the hydraulic pump at max 80 psi?*

YesNo
Hydraulic Pump Comments
Pressure Truck - If loading enter shear pin size and if pumping pressure enter PSV setting*
Shear Pin Comments*
Can driver produce a valid annual test certificate for pump discharge hose? (Hoses must be certified Yearly)*

YesNoN/A
Annual Test Certificate Picture

Take Picture / Upload File

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Can driver produce inspection certification on all hoses? (Hoses must be certified Yearly)*

YesNoN/A
Belly Hose Certificate Picture

Take Picture / Upload File

Cancelof
Load Hose Certificate Picture

Take Picture / Upload File

Cancelof
Service Hose Certificate Picture (if applicable)

Take Picture / Upload File

Cancelof
2nd Service Hose Certificate Picture (if applicable)

Take Picture / Upload File

Cancelof
Certification Comment*
Is there a positive air shutoff and function test passed?*

YesNo
Comment
Date of Passed Function Test*

MonthDayYear
Date
Are wheel chocks being used?*

YesNoN/A
The most common deficiencies for PPE includes non safety rated sunglasses being worn instead of safety glasses and personal monitor not bumped in the last 24 hrs or not being worn at all.
Is worker wearing all PPE required to do task safely? If the answer is no, please enter actions taken in comments box below.*

YesNo
PPE Comments*
Is there a fire extinguisher readily available that is inspected monthly and certified yearly? (If the answer is no, please enter actions taken in comments below)*

YesNo
Fire Extinguisher Comments
Is there a relief driver accompanying the driver?*

YesNo
Do they have all required PPE ready and on hand if an incident occurs? For Midstream, do they have a valid orientation card? (If No, they can not participate in the task/incident)*

YesNo
Were there any other deficiencies that were discussed with worker? (If the answer is yes, please enter actions taken in comments below)*

YesNo
Deficiency Comments*
Deficiency Picture

Browse Files

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Trucker/Pressure Truck Observation Form

Information