Table E Optional PSM Wksht (for PSM Eval Wksht)

Table E: Review of Equipment Inspection Records (Optional)

Equipment (insert equipment description, serial number or other identifier and inspection date)	Location of spot checks	Name/ Position of person who conducted the inspection or test?	Describe inspection or test performed and results? (29 CFR 1910.119(j) (4))	Procedures followed (e.g., manufacturer’s instructions or other accepted sources*; 29 CFR 1910.119(j)(4) (ii))	Were recommendations followed for testing, inspecting, or replacement frequencies? (29 CFR 1910.119(j)(4)(iii)) YES/NO Explain	Were identified deficiencies corrected (29 CFR 1910.119 (j)(5))? YES/NO Explain	Additional Evaluation Findings/ Corrective Actions
Pressure vessel
Storage tank
Piping system/valve
Relief/ventilation system (include relief valve)
Emergency shutdown system
Control systems
Pump and/or compressor

(*Other accepted sources include: American Petroleum Institute (API) 570, Piping Inspection Code: In-service Inspection, Rating, Repair, and Alteration of Piping Systems; and API 510, Pressure Vessel Inspection Code: In-Service Inspection, Rating, Repair, and Alteration, RAGAGEP)

1218-0110

Expiration: 4-30-28