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Job Clearance Form <br /> CONTIRArTaR 0,18tUCTKI61S PRIOR TO START OF WORK: 1:Retriaw fd;m,d"app b6fifes road alAprr* b.Dbm of this tam Z Infam dealer,i rageror tfettys of the job to, performed and potential safety concerns and obtain signabtiie, <br /> Station ft Station Address: / _- _ <br /> a Work Order Nulnfi�er -_ Date: <br /> ontrac nr <br /> CompanIll- <br /> yName: In;,Chage )' ` Nwnber0Wolim-, JSAReferenwNurnto SG IWW End7ote.- Labor: TreuelTime: Travel Mom- <br /> i, it <br /> ProblemPWork Description: t <br /> Return Gail: yes t no <br /> Damage Claim: yes/no <br /> PPE REQUIRED(CHECK ALLTHATAPPLY AND OR FILL-IN"OTHER"BLANKSPACE) <br /> ICISAFETY VEST ❑HARD HAT SNOESIBOOTSW_MM G MwnrTIOlt U RESPIRATOR <br /> PROTEMME CLOTHING Q GLOVES fo SAFETY GLASSESIGGGGLES ❑FIRE RESIST CLO 111NGIWELOING PPE Q OTHER <br /> Task Step Not Covered by.JSA How to redwo or eliminate rrsk--include extra PPE to be Won <br /> - -- ---- ' -�----= - - '- -- ------------ [ --- p,:�7---------- <br /> --•.•'-.r-_ f --' }% 3 - ' b <br /> 'd7 <br /> � -P . <br /> --------- <br /> ---------- <br /> A - - - __-__---__---- - __-_-------------- ----------- -111____-• _--------- —---------------- ----- <br /> - <br /> w = - ----- ---_ n-.-- -- ---- -_------------------- _ <br /> ------------------- <br /> --- ----- <br /> --------------------71-- -- -- -- _ = -- <br /> m. <br /> "1Nork doeumentatlon requirements Lower Risk-This form maybe used as JSA =` Medlum ft7HiWi M&-JSA Required Higher Risk-JSA Required and other custon ier-requirements may apply <br /> E.xamt>les of hlsfherimedium Risk Tasks ❑Works at heights 'Work in confined spaces(ex.Tank,interceptor,or manhole entry) <br /> ❑Trenching or excavating ❑Hot Work <br /> HoistingAgging/Heavy Uttlng j]LPG system degassing,Installation or maintenance <br /> This lorrn MUst be completed for ench joband undated and re-sign:!d it circums�ances chnnge er additicn3l h3zwds ore identified <br /> Gdritraptor rive name Signature _ SIGN OUT AND OPERATOR VERIFiCAIION OORK (bntrsetgr signature' <br /> flperalingslli*to besigned the site re tatrve sAfETY CHECKS a NTRACTOR <br /> Y CO <br /> Noo-,wr Ung sites:to be signed by Contrartor ' j r i t �- - •Hail work area bow left tidy and safe? <br /> representative only Is the site operator o,aare of status of work includig'any renainirtg isolation? <br /> Contractor responsiblity to inform site of Site representative name Signature •Are manges to equipment Site represeMalive name signature <br /> • Hazards of the job, documented and communicated? <br /> LO Rt •At incidents,rear misses,unsafe <br /> • Effects on the site or operation, ' sicvatloas reported?• Any affect to gasoline deliveries, ! r `�f �� �" srte reo;reported? CCmment I <br /> Energy isolation needed. --------------------------- ---------------- ----------- <br /> • Areas to be barricaded for worker/publicsafety. <br /> ID E.— .1 - 1=:IX Z <br /> FAFtTS-Ordered,replaced and/or disposed of(Include model and serial numbe s <br /> . a _ <br /> m <br /> AL <br /> TH <br /> It�f <br /> The contractor 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 <br /> 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 <br /> 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 <br /> WHITE:SSS/ABLE OFFICE COPY YELLOW:SEND WITH INVOICE PINK:LEAVE ON SITE <br />