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- Form 1A "Application to Operate a Guarded Plant Under Minimum or Periodic Supervision" - Nova Scotia, Canada
Form 1A "Application to Operate a Guarded Plant Under Minimum or Periodic Supervision" - Nova Scotia, Canada
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4Labour & Advanced Education
Technical Safety Division
P.O. Box 697
Halifax, NS B3J 2T8
Telephone: (902) 424-5721
Toll Free: (800) 559-3473
FORM 1A
APPLICATION TO OPERATE A GUARDED PLANT
UNDER MINIMUM OR PERIODIC SUPERVISION
Note:
This form must accompany, or be completed and submitted in addition to, the Application for Registration of a Plant
Form 1 made pursuant to the Technical Safety Act under Section 12 of the Power Engineer Regulations.
Name of Plant________________________________________ Plant Registration # ______________
Street Address of Plant ________________________________________________________________
Plant Owner _________________________________________________________________________
Please complete Sections 1 through 6, as applicable to your plant.
”
”
”
1.
TYPE OF PLANT:
Boiler
Refrigeration
Compressor
”
”
2.
TYPE OF SUPERVISION BEING REQUESTED
Minimum
Periodic
FOR DEPARTMENTAL USE ONLY
Date of Inspection
Printed name of inspector who conducted the inspection
Signature of Inspector
Yes ”
No ”
Approved to operate as a guarded plant?
Date approved
Signature of Inspector-Examiner
June 2013
Page 1 of 4
Labour & Advanced Education
Technical Safety Division
P.O. Box 697
Halifax, NS B3J 2T8
Telephone: (902) 424-5721
Toll Free: (800) 559-3473
FORM 1A
APPLICATION TO OPERATE A GUARDED PLANT
UNDER MINIMUM OR PERIODIC SUPERVISION
Note:
This form must accompany, or be completed and submitted in addition to, the Application for Registration of a Plant
Form 1 made pursuant to the Technical Safety Act under Section 12 of the Power Engineer Regulations.
Name of Plant________________________________________ Plant Registration # ______________
Street Address of Plant ________________________________________________________________
Plant Owner _________________________________________________________________________
Please complete Sections 1 through 6, as applicable to your plant.
”
”
”
1.
TYPE OF PLANT:
Boiler
Refrigeration
Compressor
”
”
2.
TYPE OF SUPERVISION BEING REQUESTED
Minimum
Periodic
FOR DEPARTMENTAL USE ONLY
Date of Inspection
Printed name of inspector who conducted the inspection
Signature of Inspector
Yes ”
No ”
Approved to operate as a guarded plant?
Date approved
Signature of Inspector-Examiner
June 2013
Page 1 of 4
3.
TECHNICAL REQUIREMENTS FOR GUARDED PLANTS
Please confirm which of the required safety devices are currently in place and functioning properly, where applicable to your plant.
”
A.
Steam Boiler Plant
Not applicable
Low Combustion
High Steam
Device
Flame Failure
Low Water Level
High Water Level
Furnace Purge
Air Pressure
Pressure tripping
Kill Switch
tripping device
tripping device
tripping device
tripping device
device
(Please °)
<
Yes ”
No ”
Are all required safety devices equipped with manual resets?
<
Date on which the required safety devices were last tested
________________________________________________
<
Name of company/person who carried out the testing
________________________________________________
<
Yes ”
No ”
Are you enclosing written verification of the test results?
”
.
High Temperature Hot Water Boiler Plant
Not applicable
B
Low Combustion
High Water
Flame failure
Low Water Level
High Water Temp
Kill Switch
Device
Furnace Purge
Air Pressure
Pressure tripping
tripping device
tripping device
tripping device
tripping device
device
(Please °)
<
Yes ”
No ”
Are all required safety devices equipped with manual resets?
<
Date on which the required safety devices were last tested
________________________________________________
<
Name of company/person who carried out the testing
________________________________________________
<
Yes ”
No ”
Are you enclosing written verification of the test results?
”
C.
Refrigeration Plant
Not applicable
High Refrigerant
High Discharge
Ammonia Vapour
Machinery Room
Device
High Liquid Level
Low Oil Pressure
Kill Switch
Temperature
Pressure
Detection System
as per CSA B52
(Please °)
June 2013
Page 2 of 4
Refrigeration Plant Cont.
<
Yes ”
No ”
Are all required safety devices equipped with manual resets?
<
Date on which the required safety devices were last tested
________________________________________________
<
Name of company/person who carried out the testing
________________________________________________
<
Yes ”
No ”
Are you enclosing written verification of the test results?
”
D.
Air or Gas Compressor Plant
Not applicable
Not applicable ”
(i)
Air Cooled Compressors
Device
High Air/Gas Pressure
High Air/Gas
Low Oil Pressure
Fan Motor Overload
Compressor Motor
Kill Switch
Discharge temperature
tripping device
Overload
tripping device
(Please °)
<
Yes ”
No ”
Are all required safety devices equipped with manual resets?
<
Date on which the required safety devices were last tested
_______________________________________________
<
Name of company/person who carried out the testing
_______________________________________________
<
Yes ”
No ”
Are you enclosing written verification of the test results?
Not applicable ”
(ii)
Water Cooled Compressors
Device
High Air/Gas
High Air/Gas
Low Oil Pressure
Low Cooling Water
High Cooling
Compressor Motor
Kill Switch
Pressure
Discharge
Pressure
Water Temperature
Overload
temperature
(Please °)
<
Yes ”
No ”
Are all required safety devices equipped with manual resets?
<
Date on which the required safety devices were last tested
________________________________________________
<
Name of company/person who carried out the testing
________________________________________________
<
Yes ”
No ”
Are you enclosing written verification of the test results?
June 2013
Page 3 of 4
4.
EXTENDED ALARM SYSTEM
<
Yes ”
No ”
Is the plant currently equipped with an alarm system that will
audibly and visually warn the power engineer, operator or any other
persons in the vicinity of the plant of the occurrence of any abnormal
operating condition of the plant?
<
Yes ”
No ”
Does the local alarm system continue to indicate an audible and
visual alarm until the abnormal condition is rectified?
<
Yes ”
No ”
Is the alarm system connected to a continuously attended monitoring
system?
5.
ALARM MONITORING
If you utilize an alarm monitoring agency/company, please complete the following section.
Name of Agency / Company
Mailing Address
Postal Code
Telephone
Facsimile (Fax)
6.
PLANT STAFFING
Please provide the name of the chief power engineer or chief operator who will be responsible for the
guarded plant during periods when it operates unattended by a qualified shift power engineer or
operator.
Name:
___________________________________________
Certificate Number:
___________________________________________
NSID #:
___________________________________________
Telephone:
___________________________________________
Submitted by:
___________________________________________
Title:
___________________________________________
Date Submitted:
___________________________________________
June 2013
Page 4 of 4
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