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W.O.# NW1-230173 <br />O Cust Ref# : 15092506 <br />This form shalt only be cotnptofed by an Approved. Competent Authorized and QualTed person. <br />This form is re utred to be completed and posted on Ali sites where Chevron work is heir, erformed. _ <br />PwrANUPOW <br />Retajl/M&C/C&1 <br />TttiaElffrE3fi itfA bP 3ltatt WSatf•Pernnitting #£ Borth AMa&a gilt and C81 facgttiec Qn`Y- ; This Permn to be D3 splayed at J04 Site <br />SioT@ fJ€anau@r Sionatur@: I acknouied�e C' `,.ave r .,aae aw rc r' "-,r ova+ attvites --.wed by "Tis <br />permit and w:lt work with i^;e work crew `or.,rrk3n SupertrE2'7CerTf 10 safe operations <br />t nature regugad on active s,�tas before t'ss permit Deocgl*S of#eciNg) ' Y.Signa i Cane <br />Work Grdaz # E us nicht ia. Ca stiff ciao or Ma tesance work;=; tae crel <br />Who r d and authorized the work: Ltcadon: <br />Descnpten at Work to be autp.=ed by = Permit L/ -'P1 <br />L stTypes of Tools and Equipment Required: <br />en ! arne of Medical FadiNearest Aedcn� • 1Resraze Puxe# My <br />GENERAL. PERMFT REQIfOMW NTS <br />❑ aef R Issuer to Check items required bekwe and once ve to as Completed. the res sidle to to initial this town <br />rr r € 3 <br />Rsk Assessment t LPSA <br />Pre j safety briefng, a GUdi p s&nuflaneous <br />ape as - SEMOPS <br />f j All employees understand their Stop Work Authorkv and I � J <br />Res sliktY.° <br />All employees a e properly trained to the appropriate I <br />eves far €he work ds 4 b r . <br />Lir Revmw of work procedures Cj � <br />JUVJSA - required for all high tisk work <br />Q Approved 2 -way radio required on site t rri <br />ra.r <br />Area is required to be barrsr odea f <br />' <br />Approved scaffolding is required to perform dt8 job task <br />@qu <br />Fall P rt31EC� w is i i ed <br />rim 'tq£ttpmenJ required to 11@ depr@ssliriXed 0 <br />Equipment required to W drained <br />p <br />i❑ j Standby Persor; required during performance of wak Q <br />w.t <br />HEST Site Safety Plan as requ"ed <br />i {--1 Spedai PPE '.a., ""m required ! tett <br />0 ] Respiratory protectionrequired List typeregrwed, <br />i All energy sources to equipment iso4ted,1**ed and tagged using p oper Lock -out d Tag Out procedures <br />` <br />MSDS provided & Hazards reviewed 'List: � <br />Q _ Addibor4 instructions, Conditions andlet req ' etnents listed b@iow have been met <br />RiADsrT� t>aiards, ag;r;Gm&n# 3� yrersusana. scaaal re6ukarrertrta kn3thcDsni <br />ADDITIONAL REQUIRED PERMIT FORMS ANDIOR PROCEDURES TO ACCOMPANY THIS GENERAL WORI{PERMtT <br />ADDITIONAL FJES KRWT FORMS TO ME ATTACHED TO THIS GENERAL WORK PERMIT <br />__f <br />© tiLii it`d ® CQltlptf3eilt # %trim Ghfealist (LOTO) iJ Exuwaon and Trertching i L3 Hoisdeg <br />T—� <br />3..d Pre Ertuy aecidist <br />® Confuted Space EJ W kat Heights I ❑ Energized Eked cal We* 0 Gas test results <br />Q Oeler <br />PERMIT TO WORK For PetxoleumfConventence Sites t � <br />u+mrk�r sio..,at�rese: '. have raviawad and understand tine eMdibM$ of this ._— ... . <br />' fl y its itEBC#lig@iIGS. I will repM hazardous candittms ur acts 3. 4. <br />dentified on this jobslie to my superylsor or customer represeatativer kfy <br />signature indicates that i July understand and wit€fusty oomply vAt all 5 CJ Add ab a worker sgnatuses $m <br />conditions and re ,ements of this Self PerrriiW Form. ndudetl an tie tea dl tFs ae mit <br />r ensure vers permit has been fitted out sompletefy and -n to*nctPn wO. al applicable OSHA <br />t 1Wor$aafe BC requrr€reants to provide a safe workplace for all workers end myself. I will take <br />reran in Onwis p4amorloa6 Paas lira o. tsyrati� reef actor, ,o elimmale hazardous conditions or acts idenflYied on this lob site, <br />i <br />jc �y Nam <br />PerrW.vaW F*m (ddimmlyyl Twfti Cate 8 TimeWoR Com :'ttei <br />r Prfnnn e> Tv iddirrwnrr,r Time amlpm (i6 hrs maz.l <br />Ganaral Wl;:* Pertnit E tsnsl*n <br />Ma� <br />W".�AgiN—WtMlo$m11t friaY i+N 87dF.i1£ii}ft N�.� t18Yai 1ft Lite Shift hitt only by iftet 331tltd rppik grM7Gs3 Permft N,SUNr - <br />V7ate: j Ehtens;an Time From �._...� a..-- <br />', perrnik Isstillr tai raak„•�re reatslred`;: � Gem a;t. t ar^� _ J <br />.. Gerharal1r1'Orts:PorrnitRenewal <br />ii'IgS iGtl: [tic ba rane"!6'Bd L fr11$ 4IXgaKUt{YY Gi tWiK WT63ld07t8 rgilet tN }�Yaltfdtted aYSt'' d! '. <br />s r to a batow dicates € r uitenents and condi`Juns of )is G'AS'P and referenced forma rerran in eftetn and re xak can be rwAirmee safe <br />uu.•Gr san...�ss fr mau+redy ro as rerarMdem thss ImrR srt err � atterhadar�e0ven�f Goriest °�teC3fr si>ear. <br />' Tice t41ieN'OILN a GEr>Ei�tYIXK PERr14 . L'brt(hnd S are E a rid. <br />Ante Vaud From vald i D Pem. t lssuia- signator@ Ex end to: Perini issuer - signature <br />star[ time) end time renewal sate ga an rwml extension <br />Revised tviay. 2WO t2te51 version c ire aowmaoaoea ar n ;rum ti. . ­­­ a <br />—12 <br />44'a+' <br />GSGS <br />