COMPLIANCE INFO_2007-2013 - Laserfiche WebLink

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All This form shall completed by an Approved,Competent,Author d Qualified parson. Th fs form Is required to be atnd on Ali sites where Chevron work is being d. This Permit to be Displayed at Job site --------------- Store Manager Signature: I admowledge that I have been made aware of the work activities covered by this permit and will work with the work am breman/superintendent to coordinate safe operations. nature 25uired on active sites before this MR becomes effective St re/-4s manaw or Signahae I Date Work Order# Equipment ID: I Construction or Maintenance work Ckcie one) Who requested and authorized the work: Location: 75$ 4, Description of Work to be authorized by this Perm ,6i"y,60, s4, �-s-M,P, 1—, 2A CZ- c UsT iN510 List Types of Tools and Equipment Required: b1AH0 -7'00L,5 Nearest Medical Facf Phone# - 3 5-1 Sou Name of Medical Facil' : ETMenI Rescue Phone# I Directions: Rf?Q. 0 Permit IpW to Check items required below and once vel'hart as completed,the responsible rtv to initial this form ® Risk Assessment/LPSA ® Pre-job safety briefing,including simutaneo us operations-SIMOPS ® All employees understand their Stop Work Authority and ® All employees are property trained to the appropriate Responsibility. level for the work they will be performi22 ® Review of work procedures ❑ JLA/JSA-required for all high risk work ❑ rem Approved 2-way radio required on site Area is required to be barricaded ® e Approved scaffolding is required to perform the job task ❑ m Fall protection is required Equipment required to be depressurized Equipment required to be drained ❑ car Standby Person required during performance of work ® HES/Site Safety Plan as required �y Special PPE andfor clotting required List: Y6G Sa 71% Respiratory protection required List type required: All energy sources to equipment isolated,locked and tagged using proper Lode-out&Tag Out procedures MSDS provided&Hazards reviewed List: car Additional instructions,conditions and/or requirements listed below have been met Additional l aW$rmnt site precaukons, is or in Ions: ADDITIONAL REQUIRED PERMIT FORMS ANDIOR PROCEDURES TO ACCOMPANY THIS GENERAL WORK PERMIT —ADDITIONAL PAGES PERMIT FORMS TO BE ATTACHED TO THIS GENERAL WORK PERMIT— ❑Hot Work ❑E uipment Isolation Checklist(LOTO) ❑Excavation and Trenching ❑Hoisting/Rigging ❑Pre Entry Checklist ❑Confined Space 10 Work at Heights 10 Energized Electrical Work ❑Gas test results ❑Other PERMIT TO WORK For Petroleum/Convenience Sites 1. 2• Worker Sianatures:I have reviewed and understand the conditions of this permit and its attadtmants. I will report hazardous conditions or ads 3. 4. identified on this jobsite to my supervisor or customer representative.My signature indicates that I fuly understand and will fully comply with all 5. ❑Additional worker signatures are conditions and requirements of this Self Permitted form. included on the back of Cue permit I ensure this permit has been filled out completely and in conjunction with all applicable OSHA Perms In Cha udhod d Fenn /WortkSafe BC requirements to provide a safe workplace for all workers and myself. I will take i� :lam" regi ) action to eliminate hazardous conditions or acts identified on this job site. Company Now., Pemdt vat From: Cal /,2-7! dd/m Time: •oC, Date&Time Work Completed Permit expires To: I ! ddt Time: :v m 6 true max. 7:Ort '. g ill'. z A e„ 4 u Date: Extension Time From: To: Penrit Issuer nature r iced: Com an Name: ' y ,r,.✓a,. fin.. 0w I NP aa, AL,.- :. My nature below indicates DIA requirements sand conditions of this GWP and referenced tams remain in effect and the work can be performed saiely, Nowa: t)Gas Test result(d rowked)to be recorded on this form or on at abaW supplemental Gas Test Record SIS 2 Tla eeneaal da Work Permit invoWo Conkied Space Entry is probiblied. Date Valid From Valid To Permit Issuer-signature Extend to: Permit Issuer-signature start tine) (end time (renewal) same day on rend extension Revised May,2010 Latest version can be downloaded at http//wwkv chevron com/nroductVSafeWorkPraoceslpfo.am