COMPLIANCE INFO_2012 - 2013 - Laserfiche WebLink

Home Browse Search

This form shall only be completed by an Approved, Competent, Authorized and Qualified person. This form is required to be completed and posted on All sites where Chevron work is being performed. Chevron - NAPWTWPO "'ber GW-' General Work Permit Retail/MMC & 1 Slaim t/lDoW Tina This Permit is to be used for Self -Permitting at North America Retail and = facilities only. This Permit to be Displayed at .lob Site Store Manager Signature. 1 acknowledge that I have been made aware of the work activities covered by this permit and will work with the work crew foreman/superintendent to coordinate sate operations. Si nature =wired on active sites before this permit becomes effective Pz% ktlager r> nee Signature/ Date Work Order # tu I I Equipment ID Constructiona nt rk ' e) Vft requestedind authorized the work: Location: tr Description of Work to be authorized by this Permit: List Types of Tools and Equipment Required __ A Nearest Medical Facility Phone # Name of Medical Facility: EmergenAl Rescue Phone_# _ Daections: _ _ _ 1 �_----^.-�-- -•---- GENERAL PERMIT REQUIREMENTS ,xl Permit Issuer to Check items required below and once verified as completed, the responsible party to initial this form Q Risk Assessment I Li�SA I f Pre -job safety briefing,includingsimultaneous j ---I- All employees understand thea Stop Work Authority and I operations • SIFAOPS _ All employees are property pained to the appropriate I 4 I "" Responsibility. Q level for the work they will be performing ❑X�- Review of work procedures { ❑ l .-msµ JL.A/JSA- required for all high risk work ❑ e�. Approved 2 -way radio required on site nwti Area is required to be barricaded ❑ .� Approved scaffolding is required to perform the job task Fall protection is required mk Equipment required to be depressurized ❑ Mroti- Equipment required to be drained — - ❑�-�� _ Standby Person required during performance of work ❑ HES / Site Safety Plan as required —_— ❑ coati Special PPE and/or clothing required List: i ❑ Respiratory protection required List We required: ❑ ! c a,� Ail energy sources to equipment isolated, locked and tagged using proper Lock -out &Tag Out procedures ❑ ( 1,1SDS provided & Hazards reviewed List ❑ �ry Additional instructions, conditions and/or requirements listed below have been met. Additional hazaros, equipment, stile precautions, spe-tal requi ements or inslruciinns: 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 - ❑ Hot Work ❑ Equipment Isolation Checklist (LOTO) ❑ Excavation and Trenching ❑ Hoisling/Rig ing ❑ Pre Entry Checklist • Confined Space ❑ Work at Heights TO Energized Electrical Work ❑ Gas test results ❑ Other _ PERMIT TO WORK For Petroleum/Convenience Sites t . 2. Worker Signatures: I have r91 ed and understand the conditions of this __— s 4• permit and its attachmen I V report hazardous conditions or ads identified.m this jobsite t my skpervisor or customer representative. My 5. O Atldtional welter signatures are signature indicates that fully 4clerstand and will hilly comply with all condtims and requiLtRerus ql this bell Permitted Form. included on the back of this permit I ensure this permit has been filled out completely and in conjunction with all applicable OSHA ! WorkSafe BC requirements to provide a safe workplace for all workers and myself. I vrili take orssnn In Ch ge;a,Indaed = ..t i.9suerl. tsignatwo renu'red) action to eliminate hazardous conditions or acts identified on this job site. Permit vaf / dcVm Time: _— r Date & Time Work Completed Permit expires To: I 1 ddim Time: ' a hrs max. General Mork ermit nslon Note: A General Work Permit may be exterWed hum da hit aro shift but o b that shits' rk !Lo Permit Issuer Date: Extension Time From I To. Permit Issuer (signature required): Company Name General Work Permit Renewal This Permit may be renewed up to 6 mnsecutive day, but 000fitfona must be revalidated each day My signature below indicates all requirements and conditions of this GWP and referenced forms remain in affect and the work can be perfomed safe Noics 11 :as Test gym. lls N rcrimreo) lc or. recrxclei on Ibc (arc: nr on an atta0w supnlm.niai Sae. Teo ovr;d Sne.+. -- %; r...M •Gnewal of a ix?wai •,rwf•% PermOhnvolvoill Confineii Space Enhy i> proh Wed IDate �TValid Frcrn—? Valid Ta Permit Issuer- signature I Extend to Permit Issuer - signature I i starttime - end _ime ,crewel e coy only renewral oxlension _ ^ -_ I Revised May, 2010 Latest version can bK< dowztluadrAl at btu_//tvww cLie�irxn.con rod icislSafcVdor •i'racG'ces/nto ii gt