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W.O.# NW1-2330296 Cust Ref# : CUCO PO# 0015230347 This form shall only be completed by an Approved,Competent,Authorized and Qualified person. L This form is required to be completed and posted on All sites where Chevron work is being performed. 'Chevron - NA - l PwmhNumber General Work Permit GYN- Off/7 Retail/M&C/C&I 6latimelD.WTem 3,077,1'9 gyp.sa . This permit is to be used for Self-Permitting at Nonb America Retail and C&I facilities only. This Perera to be olspLayed M Job site �7 store manaoer Signature:I adrrrowtedoe the',I have beer,made aware of the work activities covered by this �• ? Z, i / permil and will work with the work crew foremamUperintandent to coordinate safe operations. I ! 'nature required on active sires before this perm bermes effective; !Won(oder= 2� - E tri err ID; G P f- O Consinxtienmm-work(C rte Cure) I Who requestea and authomed the work: Locatior: Description of Work to be autnorized by Dos Permit i List Types of Tools and Equipment Required: �� MF earesi Medical Faciirhl Phans:! Name of Medics;Faadih- >7 &iujk �"�5�1'►.'15'�. _____ Em Rescue Pironaa - Direct ons:_ p e GENERAL PERMIT REQUIREMENTS i G'Pe.tf in Check items required befog and once verified as cofeted.tine party to initial this form _-_---_ (' Pre-job safety brie5ng,including smultaneous - I QXp' Rek Assessment r iPSA mx } i — operations-SIMI)PS -- i ! Alf errgmloyees understand ttleir stop Werk Authority and ,41I employees are property trained to the appropriate j Respe_nsibilll� level for the work tt Rev-- or work procedures '.--^-❑ ! ! P-VJSA-requited to,all high risk work ! ❑ n;mprovrn 2-way;adic,required an Site j Area is raquired to t e barricaded —— - - ❑ i Appm s111191g 111, ro perform the job task ❑ e I Fas prciec6on is rew-eu i ant r, to W drained -- - ❑ i Equipment required to be depressurized— ❑ Equipm required -- ❑ StarMby Pe son required Wing WtIrmance of work = ❑ rA. IiES!Sile Safety Pian as required Specht PPE andror UOLhang required List:ATR L-lot &r= SeZ92,:�j4462rf ri cD✓SSf- ❑ i _ 1 Respiratory protection rEgIW List type regwred: j❑ —. r - _ 'A2 energy sources to equipment isoia!ed,Ieorc•C and tatdged;;sutg proper Lock-out&Tag Out prxedures MSDO provided&Haiarra revkvwd List- Additional: ist i❑ _ f Additional dls;rwUicns,conditions andlor tt-[priremaMs fisted below have been mol --.----��— -- i !-'GV"mR!irarads.6P%'ntil9.ya Fre2.:1G^9=7e=r1�C_'y'u^.l.nt v,an:moons• —__—__.—.___.---_—__— _-- . ADDITIONAL REQUIRED PERMIT FORMS ANDtOR PROCEDURES TO ACCOMPANY THIS GENERAL WORK PERMIT -- ADDfnONAL PAGES PERMIT FORMS TO BE ATTACHED TO THIS GENERAL WORK PERMIT- -i--- -..—_7- —�—i 0 Hut Work ❑Equipment isolatkn Checldtst(LOTOj 10 Exravatbn and Trer&hkmg ❑Hoisdhg/Wgging ! Pre ErWy Checkust� ❑ConfirieA spac>:"0 Wont et fiisgt:is 0 erergzsd F_lecuicai N/o•k _0 Gem test results ' 0 Other i PERMIT TO WORK Por PetroleumlConVenience Sites' 1mt 1,, � I'- YVcrk na,re:I lave reviewed and understand the con�Vons ci ihJs 51 5['...- — ----- par:nif enc its attachments.t will regon hazardaus cgmdiiiors or acts '3. v 14. I dank ed gn b s jobsine to my supervlm or customer rep esemztive.My (__ l skJrmattrte cmd,;ates That i tufty trndetstallC a:td will tu(;y comply wi±h ail i 5- m Additional or,et rake*signawres are corxritirrs an'reguirements of chis&Tlf Permdted For. "'d"�°n��`d�x� I e^sure rigs permit!•as beEn fii!eC cut uromptetoiy and in contactor with all appkcabfe OSHA j f ViaekSafe BC requirements to orovkie a safe workplace for all wcrkeis and myself.I will take , Pagan e:C'ia• Para aaiyrt sTjiaaxe 8C1ion to elinimale hazardws conditions at an<-identified on ti. jab Bite. �mrs.Hann."L��IGNOCOYI�---- _ l - -- - i FermR vagi Frwn. _ fddlmmr�Tone_- air n Daie&?§ne'alk C/aJmpieted i Perrriiez _s Tg. -.� ddmmh�iirre: r cur' ;fobs rax.�Q�y2 / / �. � General Work Permit ensron ;*Xe:A tee wry WIXk?®rmy.may D.GAW dad:rem daV aA kdo nlnht chin.but"by Uvet shifts•Peak period's Pmvi Issuer Date. _ _ !lim son Time Frrxn: Tc:_ i gnatwa rcgurtad t _-.. _ -?—Company Name: — General Work Permit Renewal _ The,permit may be nnawotl up to S consocutive day,but Gond t!"V must be rovalideted exh daY My sigrtaRue below indicates as requirements and conditions of this GWP and referenced fours amain in affect and Die work ran be edorlad.safNY N.M.� tr Gas Test nrst5(l kare:OdW metls fr.maor,a,na,ONsd WpWam.�tl Gas Tref Raord S,wk P'11•u,saa nl a Gaissrd Rbk PemR xndrky Cm&-W Space E*%Pr&&W _ CDote Valid From VaAd To .Penrft issuer-signature _Extend tD -- PeimR issuer-signatum tanlprmel ter>d ._ (renew_al� I(someday only) _gnewatextensAn7 ---.--_ Reviced tiur.'_'1i0 Latest carrion sn be downloaded at itij,;,�'_:_:_'r;.'r.,_•.:a::':r nr;.:;:,:::.y.,• ;�...�;•