Laserfiche WebLink
Job Clearance Form <br /> ohrnncroH IN nRra _ao- R ,, - , t « io�,r_�, noun bonom ofn ni, deal tnwr e .,.n to seri qui i.n e..na€ T �.. <br /> .dna <br /> Station A: - Station Address: _ — -Work Or er Number: _ Date: _- <br /> Contmdor Comparry Neme: Cantramrperson in charge(print name): NumberafWedem SA geference Number: StartTme: End Time'. Labor tie Timr. Travel Distance: <br /> (if required) <br /> Prob mMlork Oescriptlon: <br /> Return Calk Yes/No <br /> - Damage Claim: Yes/No <br /> ..::. .. !? . :::. PRE.:. <br /> SAFETYVEST HARD HAT FISHOES&BOM HEARINGPROTEUION RESPIRATOR <br /> E]PROTECTIVE CLOTHING 0 GLOVES El SAFETYGi.ASSFS/GOGGLES WELDINGPIPE OTHER <br /> Contractors. opc,Irm elite <br /> ''iaskhep�; <br /> Work documentation requirements Lower Risk-P.Mrequlned Medlum Rak/Hloher Risktasks-1SArequired Hl.her Risk-1SA necked&appropriate checklht completed gee below) <br /> Examples of Higher/Medium tasks: ❑ Wobs at heights:in all roses on open sites-on closed sites lfnoYSA present ❑ Work in confined spaces(eg.tank Interceptor or seep manhole entry) <br /> ❑ Trenching or excavation related to underground sank product lines ❑ Hot work with risk of product of vapour ignition <br /> ❑ Heavylihing ❑ LPG system degassing,Installation or maintenance <br /> This form most he completed for each job and updated a.cIm i,ncd if si,cirmt.as., h.,,,e or.4ditphoul ha.a,db id,,i <br /> SIGN'INCaMrador representative name SignatuSIGN'OUT AND re <br /> esConlmlonlgnaWre <br /> Operating sites:to be signed by the Site Representative GENERAL SAFETY CHECKS OPERATOR <br /> Non-operating sitesao be signed by contractor Representative only Has the wort area than let my and par? <br /> GENERALSAFETYCHECKS -Are sea pe,.nnsl aware Now.as. <br /> -Nm Al sire personal been inlwmMr <br /> ndutliy rtmalning Isolaiim? <br /> Sire rcpres a n.a rvena.n, liyi -ArerM1an toequipmenrdtruces ed and <br /> HrsfudtlNrver a-r «s <br /> yxrnce been lnlarmetla mmmunioretli Site representative name Signature <br /> 11.Too rl S<451ed jnbrinnn tmrh rnh(rartor -Aq'ntldents nearlmdenrs,unindso <br /> -IsafueldNberytluei eymal t°^s <br /> -NaveisoUtlenpraetluresbeen agreed-IutautNgpup .OtFee <br /> -Artwork arecwdonM onto Poster wades.site stafl6 pupublic? Slt<R ttsentative comments <br /> es <br /> -.Mer <br /> PARTS-Ordered,Replaced and/or Disposed Of(include model and serial Its as apporpriate) <br /> The contractor through its authorized representative shall sign,Issue and be solely responsible for all fob clearance forms and the obligations arising there under applicable to the work <br /> This form covers important reminders and is not)mended to rekave the contractor from safely performing the work in compliance with all applicable laws and regulations <br /> The store operator may require the contractor to stop work if it appears that the contractor or any of as workers are failing to comply with the requirements in the applicable items efthis form or other applicable safety requirements. <br />