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worK VraUr: G6 r V*Luu •. <br />YL�aia ?A5y. 2trlo Thin Jeff rwo tk ¢r—t-xd br a Ys7'dG-&at Work?VM1 ?W L <br />Chevron - NA F2efa111A1l&C(C24i Permit-lo-Work Forms to b4 used wlth a General snrork Permit <br />For use at Chevron - NA t3e#�lialM$rClC&I Petra leumlGortvet�llanca 8rtns <br />This farm Shall 4rrl be cam rated !3 an raved,. Cam etant, Authnrlxat! and Quallftoti Peraonf <br />ANwsphrticTrstr (Pro- Trna u + h7t � %LLL Taracity IF+:5, 5eatane- L7 <br />kaieticxr d 44n'JtaHnnl19.5°�.�3.34F:` pp <br />Souris fealaHen E7aciriiai LC1Tam <br />O ❑YES ❑ NO <br />fn'��trY7 Fum afl8 LDTO ❑YES ❑ NO MA <br />tines G1+Ot>t.'tl -OYES ❑ NO WA <br />'Jshes ahcrt end LC1T0 OYES ❑ NO <br />Nyle: ff an>r �r0'° IM emecfrad shove arAamae<pherlc fasts aro aatslde• of fill <br />orrp�, fli out 'F4rrnrf RpWrad Gumfhred Srwee Enby <br />P4rmk"fActivn, kaq °Yes"or'7�IA'Canllnue wt, <br />Abnot<Rh6re IAecharri�cai Farrxd Ai 1J YES ❑ NO <br />V!AHIaiJoA: l,levlral It1m41a6an (jn %�YEs ❑ N6 ❑ NA <br />MttLbPhuk Taps iPoft• Tane: �, yj l}, � . spam 'i ya t�L ,�` ToFirxty <br />hclalfon i YantrlaUcn + 19.59423.0 : i� HaS. Benzene)_ <br />Pro• Sufrauntii Area Free of Hazards? YES ❑ NO q FIA <br />Entry pr n�Ylkatiune made? YES .. 101 N� ❑ NA <br />Chedt pve5 ypur knnuiedrda lAdNata the area wW reanalA iree d all �Ti'ES ©NO O NA <br />LW a enc I,Rards7 <br />At4 aiI 6MraAti 4airrad u� gatir,ed E3 Cl NO ❑ NA W <br />IS t»e as �.�.. trained AIM xe�xtri.ed? E5 q Nf� ❑ NA <br />Has the rAQata been caiibraled Gefvra use? YES ONO C7 ►U: <br />d+d lest Are stn ere n the befAra ES ❑ NQ ❑ NA <br />fAd thr, ero ffi table? ,AYES ❑ faR Q NF. <br />Wtl the w be coAlinuow rnmby pLan ore<f] AYES ❑ NE7 ❑ NA <br />M ilne wom nd eMbrl canTined aces DYES ❑ NO '�,NA <br />TenpyraWre d ceatiLad aparp aec�ble rarpefarcnOp $YES ❑ NO ❑ iVh <br /><3F.8' C n 100' 7 <br />Area barricaded riitlr W2mi db iutalkd7 ES ❑ NQ ❑ NA <br />Site c resare atia<.tred ireLaiA wigh 7 ❑YES ❑ N�! NA <br />Tralnea res+xla rFef end rescue ui an hisrrd't ❑YES ❑ NO <br />M txrt�ed SfidC9 �m uAegt an Inert aLiw,phere, wIty by n aerates D YES I ❑ NO <br />fSStfl�Ed q OpltraCtlX aDiM it ■�9rt <br />NOTE: IF ANY OF THE A90YE ANSYf£RS PIRf "Ho", DO kipT F_h1TEH <br />Jddikndhazxd�.eyq�a�ltir 2G9Iant irBmguw J�remrieanatinrinc: <br />ffq«j, a- - <br />Fu <br />,4ttendsifs• 1. ---f 2. ErrfianCs 1. 2 <br />4. <br />Pre•1=lIi3Y Checks: ❑LOTp ❑ ReSh�e Pian ❑Secure Plea aGaa <br />C7PPE Q Lines 15ai3f2l7+tl8tlrgd Q t7 Fre fur+1 :lfslsar <br />❑Pu hint woo it Permit Q Q L. <br />Illnhrum rrnrarrhTo6aCan 1 Entry <br />Cartieiu4u5 Test aVlbwaiole Initials Titl&: Tiro: e: rens 71rnr, <br />elnxwtere Ihnits <br />�'�+'A' en 19.54:��3.0°A 'yw uslue. 'v31w �+,a: vrA,a: <br />Mn. Test Freq LEL o9& Iw+� t aK vawie Y,�,n riY,e: W4c <br />�nuttrs wmxpp►�sst <br />I•k,4 < 5 PPYA vfa v�lua 'Jahr va4►: vaba: <br />97rer '� `+*.* <br />ttemaAls: <br />%as T+�terldeAel'1+16deL'SErla1 Nrmbr. IrtSpnunlfuC,athratioFi 6�; <br />tia4e all of fie condPiorrs shwa beery YES ❑ #iCy ❑ <br />A+fertdarrt r3alure: En Su 'SDr nage: <br />I ensuro ire parrriithaa been � nA and fn ear�unshan MIlr1 aQ appliszrbie OSHA k�txlLSala BG regliremertts to 'Ari S3NR+rC+rPlarefor <br />all wcekers end I rn71 eke eQiorr lv efrnnlaia haxaraLers xndltrAns a acts irkn rn Gss �. <br />Perntk hauar >;I r$ Ld Corn n Name' <br />TAtre Issued' arn' Wile: Ikafe 3 Tme SYarir Conpt�c+d: Aseasia�d [;enerai 44rxk Perrma <br />Tnrie Etc arn' 16 fus mex. Na. <br />❑ Ctred; t Gas Test is ❑ Cheer i(canfinurars bag i is ulred Msut dcb ❑ Addiborral ac Dost ntrsuRs form etlacfred <br />' rias Auttwdxed <br />Tesiq GesTester <br />i]a�la: race °tib LEL1-FL % DF FQS - PPM <br />Tanknology Inc. 11000 N. MoPac Expressway, Suite 500, Austin, Texas 78759 <br />Utltcr Rasul� 9Vre� Ra4r1t . InssuMrtl - bii� <br />Tanknology Inc. 11000 N. MoPac Expressway, Suite 500, Austin, Texas 78759 <br />