COMPLIANCE INFO_2009-2011 - Laserfiche WebLink

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CONTRACTOR INSTRUCTIONS PRIOR TO START OF WORK Address:e I form 1. Review form, check appropriate boxes, read and sign bottom of form 2 In dealer, manager or representative of the job to be Station # U- -� Statwn , Contractor Company Name: Wayne Pe 'L}� Work Order Number. �O 1) 57 Inc-SoGal y �' Contact person Ir�Charge�(printnayae�:a Number of Workers: JSARPfP._.._nl,�..___ _ ._. (if required) ai`.-. and potential safety concerns and obtain Return Call: yes ! no Damage Claim: yes / no Lj RD HAT OEs/BOOTS ❑HEARING PROTECTION POTECTIVE CLOTHING Q.6COVES ❑ RESPIRATOR ETY GLASSES/GOGGLES ❑FIRE RESIST CLOTHING/WELDING PPE ❑OTHER v. ve c. x• ea 6vv Task Step Hazards Not Covered b JSA " How to reduce or eliminate risk — include extra PPE to be worn ------------------------ ------------------------- -------------------------------------------------- ------------------------------- ------ --------------------------------------------------------------- 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 re uirenn may apply Examples of higher/medium Risk Tasks Permits -to --work are mandato for all of these activities see API RP #1646 A endix B3 for permit form)y 1 ❑Work area Barricading (permit to work not required) ❑ Works of het hts ❑ 7renchrng or excavatm9 ❑ Hoistin g (permit to -work not required) glRigging/Heavy Liftin ❑Hot Work ❑ Energy rsolation (Lock Tag Try) ❑Work in confined spaces (ex. Tank, interceptor, or manhole entry) Contractor worker name Signature _ _ � ` � Contractor signature Operating sites: t0 be signed by the site .� ENERAL SAFETY CHEC representative. Non-operating sites: to be signed by Contractor representative only :ontractor responsibility to inform site of. • Hazards of the job, • Effects on the site or operation, • Any affect to gasoline deliveries, • Energy isolation needed, • Areas to be barricaded forworkedpublic safety. PARTS — nra> A -i —. � KS BY CONTRACTOR V1r • Has the work area been left tidy and safe? • Is the site operator aware of work status and any remaining isolation? representative name S ature a •Are changes to equipment ttaefo fY" 1�c tt, o leacs Fo�trrr�iittt rrte. " documented and Site • resentative name q communicated? -All incidents, near ortemisses. r , unsafe situations reported? , of (include model and serial numbers as I ne contractor through its authorized representative shall sign, issue and be solely responsible for all Job Clearance Forms and the obligations arising there under applicable io the work This form covers important reminders and is not intended to relieve the contractor from safely Performing the work in compliance with a cable laws and regulations The site operator may require the contractor to stop work ff it appears that the contractor or any Of its workers are fait to comply with Ute n9 P Y requirements in the applicable items of this form or other applicable safety requirements