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arcadis.com <br />Waste Containerization and Sampling JSA_pv <br />Page: <br />4/4 <br />TEAM Chevron -Job Safety Analysis <br />JSA Acknowledgement <br />“I have read this JSA, and I understand the hazards and safe work practices associated with the task. <br />If conditions change or an additional hazard is recognized, I will Stop Work and notify the Site H&S Officer immediately:” <br />This JSA must be acknowledged by affected workers every shift. <br />Name Signature Initials Used on Form Date Date Date <br />PMCoW: <br />Verification of Critical Actions – Undersigned verifies that critical actions are in place, or have been evaluated based on availability, effectiveness <br />and understood by the crew prior to work starting. <br />Name of Verifier Signature Date Date Date <br />End of Day Lookback – Use this section to log changes made to the JSA throughout the day and note any recommendations for Task JSA. <br />Brief description Lookback Lookback Leader Name Date