COMPLIANCE INFO_2005-2010 - Laserfiche WebLink

Home Browse Search

Chevron - NA Retaii/P&FO Permit -to -Work Forms to be used with a General Work Permit For use at Chevron NA RetaiUP&FO Petroleum/Convenience Sites NOTE: Chevron requires 0% LEL within 501t of where not WorK is to taxe lace. riease taKe me 11ece55ai Y lJ1UVdUWi lb- -Category -of -Work----- - --- --- --- — - — - -- ------ -- -Describe:__ _ --- []Welding OCutfing ❑ Drillin []Gdndlnq ❑ Sandblast ❑ Other Which of the following special precautions are required? Check all that apply. ❑ Inspect Excavation ❑ Adequate Bonding ❑ Local Rectifiers Off ❑ Lock -Out Tag -Out (Supplemental EIC Form) ❑ Fuel Delivery ❑ Hvdrocarban soils nearbv ❑ Vent Stacks ❑ Other vapor hazards list): © Permit Issuer to Check items required below and once verified as completed me responsime paWill n Fire Extingulsher(s) located at job site [� Spark containment required ®Special PPE andfor clothing required List mires Additional instructions, conditions and/or requirements listed below have been met. Has Chevron Equipment Isolation Checklist (EIC) been completed? n c_ Has "One Call" performed utility mark outs? YES J)_0 One Call Dig Number. p ❑ Chevron - NA Retaii/P&FO Permit -to -Work Forms to be used with a General Work Permit For use at Chevron NA RetaiUP&FO Petroleum/Convenience Sites NOTE: Chevron requires 0% LEL within 501t of where not WorK is to taxe lace. riease taKe me 11ece55ai Y lJ1UVdUWi lb- -Category -of -Work----- - --- --- --- — - — - -- ------ -- -Describe:__ _ --- []Welding OCutfing ❑ Drillin []Gdndlnq ❑ Sandblast ❑ Other Which of the following special precautions are required? Check all that apply. ❑ Inspect Excavation ❑ Adequate Bonding ❑ Local Rectifiers Off ❑ Lock -Out Tag -Out (Supplemental EIC Form) ❑ Fuel Delivery ❑ Hvdrocarban soils nearbv ❑ Vent Stacks ❑ Other vapor hazards list): © Permit Issuer to Check items required below and once verified as completed me responsime paWill n Fire Extingulsher(s) located at job site [� Spark containment required ®Special PPE andfor clothing required List mires Additional instructions, conditions and/or requirements listed below have been met. Has Chevron Equipment Isolation Checklist (EIC) been completed? 9. ins: ❑ Wet ❑ Dry €tion? ❑ Dry Strength ❑ Observe soil as it is IE3 ich Box soil or rocl 5. 6. 7. 8. ❑ Has "One Call" performed utility mark outs? YES J)_0 One Call Dig Number. p ❑ Has a line locating service marked out utilities on-site? ❑ ❑ Comments: u i u I Weather Conditions: Rainfall Last 24 hours? Water Who is the designated excavation Com etent Person? How dee Is th II Manual methods to determine soil ❑ Thumb Compression Test ❑ Pocket ❑ Plasticity i classification: Penetrometer ❑ ❑ Usual methods to determine soil classification: [3 Observe samples of excavated ❑ Observe excavation material wafts ❑ Observe adjacent surface area Trench I Excavation Measurements: Length: Width: Are barricades / flagging in lace? ❑ if> Oft. also complete re -en /reclassification Permit Trench boxes certified? ❑ What is the Soil Classification? 10 Stable Rock(vertical) ❑ Class A 314:1 ❑ Class B 1:1 Which Drotective systemfs) is used? JOSloping ❑ Sharing ❑ Trench Shield(frei Tension cracks observed along slope top? 9. ins: ❑ Wet ❑ Dry €tion? ❑ Dry Strength ❑ Observe soil as it is IE3 ich Box soil or rocl Have proper notifications been made? -1 ❑ ❑ An area of unusually weak soils or ma nas I u i u I I Is there an exit or entry point within 25 feet of each worker? ❑ II Any noted dramatic dip In bedrock? ❑ ❑ i Spoils, tools. Equipment >2 feet from excavation ed e? ❑ ❑ Short term excavation <24 hours)? ❑ ❑ Are barricades / flagging in lace? ❑ ❑ Trench boxes certified? ❑ ❑ Is high visibility clothing being properly wom? ❑ ❑ Tension cracks observed along slope top? ❑ ❑ Utilities or structures rotected? ❑ II Hydraulic shore pum ed to designpressure? ❑ ❑ Underground lines osed? ❑ ❑ An water seepage in excavation walls or bottom? ❑ ❑ Bracing system installed according to design? [30 Is shoring secure? ❑ ❑ Evidence of shrinkage cracks in excavation walls? ❑ ❑ Trees, boulders, or other hazards in area? ❑ 1 ❑ Evidence of caving or sloughing of soils? ❑ ❑ Vibration from Traffic 1 equipment bein too dose? ❑ 1 ❑ Are slopes cot at design angle of repose? 13 11 Underground utilities (piping, electric, etc.) located, ❑ ❑ verifledand marked? NO TE:Excava(Ions deeper than20feetmusthave protectfvesystems des: nadb V aRegistered ProfessionalEngineer Observations: 1 hereby attest that the shove conditions existed and that the items were checked or reviewed during this lnspec6on: Competent Person Signature: Version: 04182007 "Ibis form must be accompanied by a valid General Work Permit - � Page 2 -.