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Home My WebLink AboutDRC-2025-002244 CLIVE SITE LETTER OF TRANSMITTAL DATE: 7/1/2025 ATTN: LLRW CC; Treesa Parker Karen Kirkwood RE: Transmittal 2025-040 Description of Documents Transmitted Qty See attached updates for Qualification Forms. Q1140 Rev 4, Lift Truck Operator 1 Q1141 Rev 5, Extending Boom Rough Terrain Lift Truck Operator 1 ------------------------------------------------------------------------------------------------------------ Please replace your current procedure revisions with the documents within this Transmittal. You are not required to sign any documents to verify receipt of this distribution. However, you should make every effort to ensure that your copy of the License is current. FROM: EnergySolutions Document Control Clive Facility CL-TN-PR-100-F7 Revision 1 QUALIFICATION CARD Page 1 of 3 EMPLOYEE NAME ___________________________________________ QUALIFICATION #:QUALIFICATION TITLE: QUALIFICATION APPROVAL: 00 SCOPE: THIS DOCUMENT APPLIES TO PERSONNEL WHO ARE OR MAY BE REQUIRED TO OPERATE A EXTENDING BOOM POWERED INDUSTRIAL LIFT TRUCK THAT IS OWNED OR OPERATED BY ENERGYSOLUTIONS. IN ADDITION, ANY EMPLOYEE HOLDING THIS QUALIFICATION MUST REQUALIFY EVERY THREE (3) YEARS, TO INCLUDE A PIT PRACTICAL SKILL REVIEW (FORM ES-SH- PR-608-F2). PREREQUISITE TRAINING/QUALIFICATIONS: DATE COMPLETED INITIALS DEFENSIVE DRIVER TRAINING COMPLETION OF THE Q1140 LIFT TRUCK QUALIFICATION (ADD ADDITIONAL LINES AS NECESSARY) PREREQUISITE READING MATERIALS: DATE COMPLETED INITIALS APPLICABLE EQUIPMENT OPERATORS MANUAL JHA-CL-GF-4536 EQUIPMENT OPERATIONS (ADD ADDITIONAL LINES AS NECESSARY) QUALIFICATION CRITERIA: SME SIGNATURE DATE COMPLETED INITIALS CLASSROOM TRAINING WITH WRITTEN EXAM PASSED AT 80% OR HIGHER COMPLETION OF PRACTICAL EVALUATION & PRE-USE INSPECTION FORM (ADD ADDITIONAL LINES AS NECESSARY) PRACTICAL CRITERIA: Q1141 EXTENDING BOOM ROUGH TERRAIN LIFT TRUCK OPERATOR Task (Description) Satisfactory (Check Mark)SME Date (Completed)Initials Performs the Pre-Use Inspection correctly. Qual Manager ___________________________ ___________________________ Date_________ PRINTED NAME SIGNATURE Radiation ___________________________ ___________________________ Date_________ Safety Officer PRINTED NAME SIGNATURE Yes Practical Evaluation (included) Yes/No This SECTION is filled out by DOCUMENT CONTROL. Revision No.: _5__Effective Date: 7/1 Roger Ekins Digitally signed by Roger Ekins Date: 2025.06.30 13:09:34 -06'00' Thomas Brown Digitally signed by Thomas Brown Date: 2025.07.01 05:54:09 -06'00' CL-TN-PR-100-F7 Revision 1 QUALIFICATION CARD Page 2of 3 Demonstrates ability to steer and turn smoothly. Demonstrates ability pickup, move, and place a pallet. Demonstrates ability to brake and stop appropriately. Sounds horn at all appropriate locations. Keeps forks at appropriate height while traveling. Demonstrates ability to maintain a safe travel speed. Demonstrates ability to allow clearance when turning. Accelerates/Decelerates at gradual rate. Demonstrates ability to stop with a load. Demonstrates ability to maneuver turns with a load. Inspects and Wears all safety equipment (i.e. seat belt, harness, etc.) while operating lift. Demonstrates ability to load and unload a truck trailer safely. Demonstrates knowledge and safe usage of fork extensions/attachments. Demonstrates ability to use and understand boom lift load charts. Demonstrates the ability to proper park and dismount the equipment. ALL REQUIRED ITEMS HAVE BEEN COMPLETED AND THIS QUALIFICATION IS VALID: EMPLOYEE _______________________ ______________________DATE_________ PRINTED NAME SIGNATURE EMPLOYEE MANAGER _______________________ ______________________DATE_________ PRINTED NAME SIGNATURE Verification of Completed Documentation QUAL MANAGER _______________________ ______________________DATE_________ PRINTED NAME SIGNATURE ***ONCE COMPLETE, SCAN AND PLACE IN FOLDER FOR DATA ENTRY AND DOC CONTROL*** CL-TN-PR-100-F7 Revision 1 QUALIFICATION CARD Page 3of 3 CL-TN-PR-100-F7 Revision 1 QUALIFICATION CARD Page 1 of 3 EMPLOYEE NAME ___________________________________________ QUALIFICATION #:QUALIFICATION TITLE: QUALIFICATION APPROVAL: 00 SCOPE: THIS DOCUMENT APPLIES TO PERSONNEL WHO ARE OR MAY BE REQUIRED TO OPERATE A POWERED INDUSTRIAL LIFT TRUCK THAT IS OWNED OR OPERATED BY ENERGYSOLUTIONS. IN ADDITION, ANY EMPLOYEE HOLDING THIS QUALIFICATION MUST REQUALIFY EVERY THREE (3) YEARS, TO INCLUDE A PIT PRACTICAL SKILL REVIEW (FORM ES-SH-PR-608-F2). PREREQUISITE TRAINING/QUALIFICATIONS:DATE COMPLETED INITIALS Defensive Driver Training (ADD ADDITIONAL LINES AS NECESSARY) PREREQUISITE READING MATERIALS:DATE COMPLETED INITIALS CL-SH-PR-100 CLIVE HEALTH AND SAFETY PLAN APPLICABLE EQUIPMENT OPERATORS MANUAL JHA-CL-GF-4536 Equipment Operations (ADD ADDITIONAL LINES AS NECESSARY) QUALIFICATION CRITERIA: SME SIGNATURE DATE COMPLETED INITIALS CLASSROOM TRAINING WITH WRITTEN EXAM PASSED AT 80% OR HIGHER COMPLETION OF PRACTICAL EVALUATION & PRE- USE INSPECTION FORM (ADD ADDITIONAL LINES AS NECESSARY) PRACTICAL CRITERIA: Q1140 LIFT TRUCK OPERATOR Task (Description) Satisfactory (Check Mark)SME Date (Completed)Initials Performs the Pre-Use Inspection correctly. Demonstrates ability to steer and turn smoothly. Qual Manager ___________________________ ___________________________ Date_________ PRINTED NAME SIGNATURE Radiation ______________________________________________________ Date_________ Safety Officer PRINTED NAME SIGNATURE Yes Practical Evaluation (included) Yes/No This SECTION is filled out by DOCUMENT CONTROL. Revision No.: __4_Effective Date: 7/1 Roger Ekins Digitally signed by Roger Ekins Date: 2025.06.30 13:08:43 -06'00' Thomas Brown Digitally signed by Thomas Brown Date: 2025.07.01 05:53:32 -06'00' CL-TN-PR-100-F7 Revision 1 QUALIFICATION CARD Page 2 of 3 Demonstrates ability pickup, move, and place a pallet. Demonstrates ability to brake and stop appropriately. Sounds horn at all appropriate locations. Keeps forks at appropriate height while traveling. Demonstrates ability to maintain a safe travel speed. Demonstrates ability to allow clearance when turning. Accelerates/Decelerates at gradual rate. Demonstrates ability to stop with a load. Demonstrates ability to maneuver turns with a load. Inspects and Wears all safety equipment (i.e. seat belt, harness, etc.) while operating lift. Demonstrates ability to load and unload a truck trailer safely. Demonstrates knowledge and safe usage of fork extensions/attachments. Demonstrates the ability to properly park and dismount the equipment. ALL REQUIRED ITEMS HAVE BEEN COMPLETED AND THIS QUALIFICATION IS VALID: EMPLOYEE _______________________ ______________________DATE_________ PRINTED NAME SIGNATURE EMPLOYEE MANAGER _______________________ ______________________DATE_________ PRINTED NAME SIGNATURE RSO _______________________ ______________________DATE_________ PRINTED NAME SIGNATURE Verification of Completed Documentation QUAL MANAGER _______________________ ______________________DATE_________ PRINTED NAME SIGNATURE ***ONCE COMPLETE, SCAN AND PLACE IN FOLDER FOR DATA ENTRY AND DOC CONTROL*** CL-TN-PR-100-F7 Revision 1 QUALIFICATION CARD Page 3 of 3