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Job Clearance Form CONTRACTOR INSTRUCTIONS PRIOR TO START OF WORK: 1,Review form,check appropriate boxes,read and sign at the bottom of this form 2.Inform dealer,manager or representative of the job to be performed and potential safely concerns and obtain signature Station# Station Address: f ! 7#i i ,',z , J t.., 1; _ ",. Work Order Number. ! . e i j 'f Dale: ' r" J: { j + �pnpactpr Comp 4 Name. Contdpt per on In Charge(print name): Number of Workers: A JSA Reference Number: Starl Time: End Time Labor: Travel Time: Travel Distance: -1 `) t ,c r t: . ; .i - �.1 i A ti ma,i r^ J�! r, if required) Problem/Work Description � � t 1�'t,.� i �e'-.f Jr i i-� .:it-t � ! �, i� �•, !j t,i r`-! r � a1 Return Call: yes I no i Damage Claim. yes 1 no 0 SAFETY VEST Q HARD HAT ❑SHOEWBOOTS ❑HEARING PROTECTION ❑RESPIRATOR ❑PROTECTIVE CLOTHING ❑GLOVES ❑SAFETY GLASSES/GOGGLES ❑FIRE RESIST CLOTHING/WELDING PPE ❑OTHER Contractor p- Task Step Hazards Not Covered by JSA 11 How to reduce or eliminate risk—include extra PPE to be worn 1 r? B{ 1 (, r�c' .,, .� F l : ,f r• t � (' u A 4 !'.'�1 ---�---- e -------= -------- ----------------- — --- - --------------- ----- - t------- ----- t $ - -------- _----------- j 't �/ f --- ----- •l-- , -------=------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------- ----------------- Work documentation requirements Lower Risk-This form may be used as JSA Medium Risk/Higher Risk-JSA Required Higher Risk-JSA Required and other customer requirements may apply Examples of higher/medium Risk Tasks ❑Works at heights ❑Work in confined spaces(ex.Tank,interceptor,or manhole entry) ❑Trenching or excavating ❑Hot Work ❑Hoisting/Rigging/Heavy Lifting ❑ LPG system degassing,installation or maintenance Contractor representative name Signatures • . •• - •• • • •• Contractorsignalure Operating sites:to be signed by the site representative , V GENERAL SAFETY CHECKS BY CONTRACTOR Non-operating sites:to be signed by Contractor )`��, Y� )u. _r L_ ''✓y�;r^'"��? �� •Has the work area been left bdy and safe? representative only •Is the site operator aware of status of work including any remaining isolation? Contractor responsibility to inform site of: Site representative name Signature •Are changes to equipment Site representative name Signature • Hazards of the job, Contractor has discussed Job Cietarancta Form with rite documented and communicated? i •All incidents,near misses,unsafe Effects on the site or operation, situations reported. Any affect to gasoline deliveries, • Energy isolation needed, _ Site representative comments: i i r- - t • Areas to be barticaded for worker/public safety. I V-- --------------- -- -- ------ --------------_-------------- f ��'�¢�(�,�"} ----- A T -Ordered,r r6d and/or disposed of(include model and serial numbers as appropriate) - � eos Q -- - ------------- j —LLJ LI I T tractor through its authorized representative shall sign,issue and be solely responsible for all Job Clearance Forms and the obligations arising there under applicable to the work This form covers important reminders and is not intended to relieve the contractor from safely performing the work in compliance with applicable laws and regulations The site operator may require the contractor to stop work if it appears that the contractor or any of its workers are failing to comply with the requirements in the applicable items of this form or other applicable safety requirements WHITE:SSS/ABLE OFFICE COPY YELLOW:SEND WITH INVOICE PINK:LEAVE ON SITE