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W.O.# NW1-2323217 This form shall only be completed by an Approved, Competent, Authorized and Qualified person. Thls form Is required to be completed and posted on All sites where Chevron work is beinga to, cid Chevron - NA Pxmh Neml»r General Work Permit GW- C Retail/M&CIC&i SiadonslDNI/Tvne _;'.0770q 3;10 _ This permit Is to be used for Self -Permitting at North America Retail and C&I facilities only. This Penmt to be Disptayad at Job silo Store Manager Signature: I acknowledge that 1 have been made aware of the work actrollies covered by this 1� permit aril will work with the work crew foremanisuperinterident to coordinate safe operations. (Signature r9luired on acM arias before this permit becomes effective suer or ynemxaf Date Work Ord* #._...s2$ ^ anti 1 E ui t 10: _.._...._ Construction or Maintenance q tle cue) Who requested and authorized the work: Locatlai:149-1237 Description of Work to be authorized by this Permit: Ijtsy6L LSA JG (7�ft�C t tet' -- �._ypes Uat Types of Tools and Equipment Required: IJA vo Nearest Medical Facility Phone # 1 4111 1 Nam; of Madical Facility. Emergency/Rescue Phone# I IT I Id ewdons: GENERAL PERMIT REQUIREMENTS ' Cor Peart t I mm er to Chad Items required below and once verified as rDm lets d, ft responsible to initial this form Risk Assessment / LPSA Preaob safety briefing, Including simultaneous operations • SIMOPS All employees understand their Stop 44ork Authority and Responsibility. _ Ap am yeas are pro Ireinad to the appropriate level for the wor0a will be performing _ QX Review of work procedures ❑ j JLAUSA- requir "&r a1i high risk work ' ❑� Approved 2 -way radio required on site Area is required to be barricaded r Approved scaffolding is required to perform the job task ❑ ............ Fall protection le required Er Equipment required I. be depressurized IV Ecuippnent required to badrakted 13Standby Person required during performance of work ❑ HES! Site Safety Plan as required Special PPE androrclothing required Lite 2LtG S.E1:i V vG9t' Aeav6St '�tAidh$ '—a ❑ na.. Respiratory protection required List type required: ❑ _ Ali energy sources to equipment isolated, locked and tagged using proper tack -our & Tag Out procedures ❑ wa MSDS provided & Hazards reviewed List: ❑ .,e.. Additional instructions, conditions and,ar requirements listed below have been meL Additoml haunts, *gWpeent txa prewutirt ;t.edai rpunamaMs a 1n66,a6or6: ADDITIONAL REQUIRED PERMIT FORMS AND/OR PROCEDURES TO ACCOMPANY THIS GENERAL WORK PERMIT -ADDITIONAL PAGES PERMIT FORMS TO BE ATTACHED TO THIS GENERAL WORK PERMIT- ❑ Hol Work ❑ Equipment Isolation Checklist (LOTO) 10 Ezcavatbn and Trenching ._. ❑Pre En CI ecktisl ❑ Confined Space ❑ Work at Heights ❑ Energized Electrical Work ❑ Gas lest resu is ❑ Other PERMIT TO WORK For Petroleum/Convenience Sites Worker Sionatures I have reviewed and understand the conditions of this permit and its attachments. I will report hazardous conditions or acts identified on this jobsite to my supervisor or customer representative. My signature indicates that I fully undersand and will Cully comply with all conditions and requirements of this Self Permitted Form. �• 2 3. 4. 5. ❑ Additional worker signatures gra kuJuded on the bade of this permit. I ensure this permit has been filled out completely and in conjunction with all applicable OSHA Zia I WorkSafe SC requirements to provide a safe wvrkpace for all workers and myself. I will take Pe e'" in c umv'aad PWrIll uwo,) (tireG d Wglhdl action to eliminate hazardous conditions or acts identified onthis Job site. Carparc! Name: �AfJiGA.d4`+'� _ Perms vatd From; fe$ ! ddtmm ) Time a..... Date& �{ma Wgrk�Completed Permit expires To: I 1 ;ddhnmr Time: a 8 hrs max. ; QY ted' CS General WorkPermitnsion Noto. A ora Work Ponnd May be extended da shat into nicht shm, but c that SM,Rr Work derroy's fermi! Issuer Data; Eztdrsicn Time From: To: Permit Issuer (s' rat is required): ;_Company Name.--,_„____ General Work Permit Renewal This rmlt ma ba renewed u to a eenseeutive day, but conditions must be revalidated each da sit ns urs l Td cWltia:s of Ibis GWP and referenced forms remain in effect and the work can be performed safely. _Y1 Noes: ii6q Teri reauts f6retwvae)to lx reafrdedmmsfamaan a't adadbd a�pokmartoi C,as Taa Read $r'4et TMrywr at ole C-1 Werk PSmatinvelvl Cmrred aE. nproh"d. Date Valid From Valid TO Permit Issuer-slgnatJre Extend to: Permitissuer- signaturo start time end time renawal sort* day on renewal extension I i J -- i Revised ?vtay, 2010 Latest version can bit downluadrd at h}.i}+;.;„H:yyw:;tgyapol}.rv1G:.!'L•lsl.�L&i;�3itfS.lVxrr�;�,n.taT%GEIVE MAY 2 6 2015 ENVIRONMENTAL lar-arrfJ r1C0J4TAA17AIT