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• • Clearance Form CONTRACTOR INSTRUCTIONS PRIOR TO START OF WORK: 1 Review form,check appropriate boxes, read and sign at the bottom of this form 2 Inform dealer, manager or representative of the job to be performed and potential safety concerris ar StaGon Station Address / r . Work Order Number: Date: Contractor Company Name / Contact person In Charge(print name): Number of Workers JSA Reference Number End Time Labor Travef Time d required) J ProblemNVork Description: _ _ .� n �• - _ +�._,. _:��, �Z t_ 5� !� L (" t ! r /'J tr S ,f !J�� /✓ -� `L. � �./ �7 t/ � r '�..' i _fr � Refum Call: yes/no w, Damage Claim: yes/no El SAFETY VEST ❑ HARD HAT ❑ SHOES/e00TS ❑ HEARING PROTECTION ER ESPIRATOR ❑ PROTECTIVE CLOTHING [] GLOVES ❑ SAFETY GLASSES/GOGGLES ❑ FIRE RESIST CLOTHING/WELDING PPE ❑ OTHER spaceContractor to complete section below If circumstances on site or specific to this job may generate additional hazards not described In the JSA (please use back of page If additional . . . Task StepHazards Not Covered by JSA How to reduce or eliminate risk —include extra PPE to be worn - - - - - - -------------------------------------- CK-j_ -° - ( Qh/ ---_ --------- ----------------- ----------------� r- -------------------- -- - - - -- --- ----------------------------------------------- fON --------- f-- � U/'"" ------------------------------- ------------- --- - - -------- --- -- - -/!- 1 - ------------------------------------------ T �tK.!s. " z. ---n '-,�- - 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 requirements may apply Examples of higher/medium Risk Tasks ❑ Works at heights ❑ Work in confined spaces (ex. Tank. interceptor, or manhole entry) ❑ Trenching or excavating ❑ Hot Work ❑ Hoisting/Rigging/Heavy Lifting ❑ LPG system degassing, installation or maintenance This form must be completed for each . . and updated and re-signed If circumstances change or additional hazards are identified SIGN IN Contractor representative name Signature OUT • OPERATOR • OF • - Contractor signature Operating sites to be signed by the site representative GENERAL SAFETY CHECKS BY CONTRACTOR A Non operating saes to be signed by Contractor d yv ( •Has the work area been left tidy and safe? �� 4 representative only •Is the site operator aware of status of work including any remaining isolation? w� -- Contractor responsibility to inform site of: Site representative name Signature •Are changes to equipment Site representative name Signature documented and communicated? • Hazards of the job, " •All incidents,near misses. unsafe • Effects on the site or operation, situations reported? • Any affect to gasoline deliveries. Site representative comments: • Energy isolation needed, • Areas to be barricaded for worker/public safety. -------------------------------------------------------------------------------------------- PARTS—Ordered, replaced and/or disposed of (Include model and serial numbers as appropriate) 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 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 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 WHITE: SSS/ABLE OFFICE COPY YELLOW: SEND WITH INVOICE PINK: LEAVE ON SITE