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CONTRACTOR INsrRueTIONs PRIOR TO START OF WORK; i,Rayiew form,check appropriate boxes,read and signal the bottom of this fofm 2.Inform dealer,manager of representative of the job to be performed and potential safety concerns and obtain signature
<br /> Station d6,��5c Station Address: 1146- ��� �� Work Order Number: 9 �a 3 �, . Dale: $�Z.
<br /> ConhdorCornponyN me: Contact person InChargo(prWnsme): NumberolW6rkers: JeARaferoneeNumber eNIff Ende: LaboE TrevelThre: Trevel0lslonm
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<br /> ProblomMlork Description: _
<br /> Return Call: yesZwoDamage Claim; ye
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<br /> [}SAFETY VEST ❑HARD HAT ❑SHOES1900TS ❑HEARING PROTECTION ❑RESPIRATOR''
<br /> LJ PROTECTIVE CLOTIi1NG ❑GLOVES SAFETY GLASSES/GOGGLES ❑FIRE RESIST CLOTHINGIWELDING PPE ❑OTHER
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<br /> Task Step Hazards Not Covered by JSA Flow to reduce or eliminate risk—Include extra PPE to he worn
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<br /> War;documentatlon requirements Lower Risk-This form may be used as JSA Medium Risk/Higher Risk-JSA Required Hlnher.Rlsk-JSA Required and other ouclamor requirements may apply
<br /> g'moles of higher/medium Risk Tasks ❑Works at heights ❑Work In confined spaces(ex,Tank,Interceptor,or manhole entry)
<br /> []Trenching or excavating ❑Hot Work
<br /> ❑Holsting(Rlgging/Heavy Lifting ` ❑LPG system degassing,installation or maintenance
<br /> `'• { "dsl�'r, Iprdtt - '� ',r,`2 ..r•�t i,�N,
<br /> 1128" RX" i 1 r `V:�.1 .1•.'� yy.,�yy_'Iff I!�{ t� �.;�.�..�rr a:ryf�:�'j;'�r a:qyl t�� • {. ;•b+r.! r •tL• F
<br /> Contractor representative name Signature ® o e• e• • a s Contracts signature
<br /> Operating¢Ilea:to be signed by the site represeniallve /
<br /> GENERALSAF /
<br /> Non-operating sites:to by signed by Contractor �, / /• •Hes the vrork aETY CHECKS BY CONTRACTOR
<br /> rea been loft tidy and safe?
<br /> roprosontauve only •laths site opeialar aware of Waive of work Including any mmehing Isotegon?
<br /> Conlractor responsibility to Inform sheaf: Site representative name Signature •Are changes to equipment Site representative name Signature
<br /> • Hazardsoflhe oh, ,, documented and communicated?
<br /> t.f ferhas .r 9 °<ift)t5b d.Qrati'pe. d, WitI9 r>313%�7 uR fi {
<br /> Effects on the silo arO eratlon, °All Incidents,near reported?ssss,unsafe
<br /> • E �.
<br /> P � siluailons rapriedl r i
<br /> ■ Any affect to gasoline deliveries,
<br /> • Energy Isolation needed, t. Vim./ `�,� Site reoresentative comments:
<br /> _ ____________
<br /> • Areas to be barricaded forworkedpubllc safely.
<br /> PARTS-Ordered,roplaced an /ordisposed of(Include rnodei and aerial numbers as appropriate) - '-
<br /> The contractor through its authorized representative shall sign,Issue and be solely rEspondbie for a6 Job Clearance Forma and the obligations arising there under applicable to'.he,York m�
<br /> This form covers important reminders and is not intended to relieve the contractor from safely performing the work in compliance with applicable lairs and regulotions
<br /> The site operator may require the contractor to stop vrork Ifit appears that the contractor or any of its workers are failing to comply with the requirements In the applicable items of[his form Brother applicable safety requirements
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