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W.O.# NW1-2330296 Cust Ref#: COCO PO# 0015230347 <br /> Chevron-NA Retail/M&CIC&I Permit-to-Work Forms to be used with a General Work Permit I <br /> For use at Chevron-NA Retail/M&C/C&I Petroleum/Convenience Sites i <br /> This form shall only be completed by an Approved Competent Authorized and Qualified Person! <br /> EQUIPMENT ISOLATION CHECKLIST(EIC) General Work Permit# <br /> Equipment Name and location: 9^444�A-5 <br /> EIC Prepared By: 6r/6 G / EIC Field Checked By: � 6 <br /> Isolation Equipment -'If Tag if lock Blind Blind I Normal Date Date <br /> Point Isolation Installed Lock Number installed ID Operating installed Initials Removed Initials <br /> Point Installed Number position <br /> 1(Primary) eJc - �/ ✓ '( 3 ZY i <br /> 3 <br /> P7 4 -- <br /> i <br /> 5 <br /> i <br /> 6 ( <br /> I <br /> B I I <br /> 9 <br /> Commekns <br /> --'"' .'�c^,.._.._' =�eE `, t,'r'''c c:�6_�e-eek a kr1_.-�,� i;,f+° x•'v?.. <br /> Has the energy isolation been reviewed by all affected persons? I Yes❑ ; WA❑ <br /> List All Affected Persons: 1 t. 2. 13- <br /> 16. <br /> r-- <br /> GAS TEST RESULTS <br /> I <br /> ❑Check ti Gas Test is required ❑Check it continuous Gas Testing is required throughout Job ❑Addtional gas test results form attached <br /> i <br /> ( Gas Authorized <br /> I !Testing Gas Tester <br /> Date: I Time %LCULFL %02 H2S-PPM !Ottler Results ;O+her I Result Instrument Initials <br /> :Ii <br /> j <br /> I _ l <br /> I <br /> • k <br /> i Has the Lift Plan been completed by a competent person? l YES NO l Qoes tfta equipment have the size,load,and swing , YES NO <br /> ❑ ❑ ;capacity to do the' b safely? p ❑ <br /> Air or hydraulic systems inspected for deterioration.or ❑ ❑ j Too!Box discussion conducted&lift plan communicated ❑ ❑ <br /> leakage in lines,tanks,valves,drain pumps.etc? I to all affected rsonnel? <br /> Hooks.hoist chains,and end connections checked for signs ❑ ! ❑ i Are outriggers set before hoisting operations NIA ; <br /> of wear,tw st,c acts,distorted links.or excessive stretch n? ❑ I ❑ j ❑ <br /> Has rigging been performed b a competent person? ❑ 1 ❑ Is proper cribbinq being used j ❑ j ❑ 1 ❑ <br /> is lite hoisting equipment sittinq on a stable surface? ❑ ❑ Overhead risks evaluated as art of the lift plan? ! ❑ ❑ ❑ <br /> is work area property barn caded(solated? ❑ ❑ Is the Operator certified for the equipment? I ❑ ❑ . ❑ <br /> Has the hoisting equipment been inspected before use? ❑ ; ❑ Are periodic inspections complete and <br /> 1 ( ! <br /> documented l� ��� <br /> NOTE:IF ANY OF THE ABOVE ANSWERS ARE-NO-,DO NOT PROCEED UNTIL CORRECTED <br /> Permit Issuer(signature required): _ _ Compan Name: <br /> Time Issued: amipm I Date: Date&Time Work Completed: Associated General Work Permit No. j <br /> ' Time ez fres: � l <br /> `_-p amlpm(16 hr max.) <br /> This form,must be aaomp.med by a4id General Work Permit p-�2 <br />