COMPLIANCE INFO_2005-2010 - Laserfiche WebLink

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This form shall only be completed by an Approved, Competent, Autnorizea t This form is required to be completed and posted on All sites where Chevron to Chevron - NA Retail/Wo General Work Permit This permit is to be used for Self -Permitting at North America Retail facilities only. PERMIT TO WORK For Petroleum/Convenience Sites Worker Signatures: I have reviewed and understand the conditions of this moi^ permit and its attachments, f wtl report hazardous conditions or acts 3. identified on this jobsite to my supervisor or customer representative. My signature indicates that: I fully understand and will fully comply with an 5r conditions and reu'irements of this Self Permitted Form, Store ManaeerSk nature. I 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 safe operations. person. Permit to be Displayed at Job KA ❑ Additional worker signatures are included Qn the back of this permit. �. I ensure this permit has been filled out completely and in conjunction with all applicable OSHA —/t --- `y `x --- requirements to provide a safe workplace forall workers and myself. 1 willaake action to _ Person In Charge (Authfted P it Iss : (signature required) eliminate hazardous conditions or acts identified on this job site. Time Issued: Date: 'y 2�h� Location Ift-a ;yy/; j pose' ��w, Time expires: ai ;`m 6 his max) Work Order# c9 Equipment ID: I Construction or Maintenance work (Circle one Whorequested and authorized the work: Description ofWoric 5.9 9T_ Iq ❑ Worldrici at het ht is required List Types of Tools and Equipment Required fa Alp 14ek L'u e^s ,,- %®� �l�A/Q 7gsa.e:r Nearest Medical Facility Phone # ;W ' YZS39 914 1 Name of Medical Facility: k Emergency / Rescue Phone# I -,-/I I Directions: GENERAL PERMIT REQUIREMENTS 0 Permit Issuer to Check Items required below and once verified as complete- the res nsible a to initial this form ❑X- ?! Risk Assessment/ SPSA X❑ re -job safety briefing 0 , -Ali employees understand their Stop Work Authority and m�v Responsibility, All employees are properly trained to the appropriate level for the work thff will be performing ❑ -Review of work procedures ❑ it JSA - required for all high risk work ❑ ausam Approved 2 -way radio required on site ❑ Area is required to be barricaded ❑ Approved scaffolding Is required to perform the job task ❑ Fall protection is required ❑ ❑ Equipment required to be depressurized 6aab mie Standby Person required during performance of work ❑ .. m Equipment required to be drained Contractor is required to provide an HES / Site Safety ❑ ink Plan ® Special PPE and/or clothing required List: mthu ❑ ewe Respiratory protection required List type required: ® All energy sources to equipment isolated, iocked and tagged using proper Look -out & Tag Out procedures MSDS provided & Hazards reviewed List ❑ w Additional instructions, conditions and/or requirements listed below have been met. Additional hazards, equipment site pre caugons, s acW ra7ements or tmtmcgons: ADDITIONAL REQUIRED PERMIT FORMS AND/OR PROCEDURES TO ACCOMPANY THIS GENERAL WORK PERMIT — ADDITIONAL PAGES PERMIT FORMS TO BE ATTACHED TO THIS GENERAL WORK PERM IT— ❑ Hot Work ❑ Lock Out Tag -Out 111 Excavation Cheddist ❑ Hoisting/Rigging ❑ Pre Entry Checklist PQ Confined Space ❑ One Can (811) - Underground Utility Locator I ❑ JSA I ❑ Management Of Change ❑ Gas test results General Work Permit Extension Note: A General Work Permit may be extended from da hilt into night shift but oniv bv that shifts' otic edod s Permit Issuer Date; Extension Time From: To: Permit Issuer (signature required): General Work Permit Renewal This permit may be renewed up to 5 consecutive day, but conditions must be revalidated each da My signature below indicates all requirements and conditions of this GWP and referenced forms remain in effect and the work can be performed safely. Notes: 1) Gas Test results (irequkedf to be recorded on this form or on an attached supplemental Gas Test Record Sheet 21 fie renewal of a General Work Permit Invomn Confined Space Entry is rohibited. Date Valid From Valid To Permit Issuer- signature Extend to: Permit Issuer -signature start time end time(renewal) same day only) renewalextension P 1 -: age Version; 09182007 `