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0 55 API RECOMMENDED PRACTICE 1646 PERMIT TO WORK For Petroleum/Convenience Sites 1. 2. Worker Signatures:I have reviewed and understand the conditions of this 3. 4. permit and its attachments. I will report hazardous conditions or acts 5 6. identified on this jobsite tom su ervisor or customer representative. 1. 8. 9. 10. Person In Charge: Date: Location Work Order# I Equipment 16: Time Issued: anv m Nearest Medical Facility 8 phone# Time expires: am/pm Eme an /Rescue Phone# ❑Hot Work ❑Excavation Checklist ❑Lock-Out Ta -Out ❑Pre Entry Checklist 113 Confined Space ❑One Call ❑Hoistin IRi in lQManaoementQLQmg9e 10 Work Notification ❑Other HOT WORK Category of Work Describe: ❑Welding ❑Cutting ❑Drilling ❑Grinding ❑Sandblast ❑Other Which of the following special precautions are required? Check all that apply: ❑Inspect Excavation ❑Adequate Bonding ❑Local Rectifiers Of ❑Lock-Out Tag-Out ❑Fuel Delivery ❑Hydrocarbon soils nearby 13 Vent Stacks ❑Other va rhazards list: Atmospheric Tests: 02: 1 %LEL: I Toxici H2S: Job Control Contact Name: I Fire Watch Name if applicable) To API 1646 Section L Has the piece of equipment or system been properly isolated? NOLN/A 0Has the ene isolation been reviewed b all afected em to ees? ❑ List All Afecled Workers: 1. 2. 3.5. 6. 7. TRENCHING AND EXCAVATION—API 1646 Section 9 Has"One Call"performed utility mark outs? YES NO One Call Dig Number: ❑ ❑ Has a line locating service marked out utilities on-site? ❑ ❑ Comments: Weather Conditions: Rainfall Last 24 hours? Water Conditions: ❑Wet DDry Who is the designated excavation Com tent Person? How dee is the excavation? Manual methods to determine soil ❑Thumb Compression Test ❑Pocket ❑Plasticity ❑Dry Strength classification: Penetrometer Visual methods to determine soil ❑Observe samples of excavated ❑Observe excavation ❑Observe adjacent ❑Observe soil as Us classification: material walls surface area excavated Trench/Excavation Measurements: Length: Width: Depth: (if>4N,also complete re-ent (reclassification Permit What is the Soil Classification? ❑Stable Rock vertical ❑Class A 3/4:1 ❑Class B 1:1 ❑Class C 1.5:1 Which protective system sis used? 10 Slopinq ❑Shorinq ❑Trench Shield/Trench Box Are Employees Kept Out of and/or away from the excavation YES NO Evidence of significant fracture planes in soil or rock? YES I NO dudn igging or material handling? 1 11 p p Have proper notifications been made? ❑ ❑ Any area of unusu Ily weak soils or materials? ❑ ❑ Is there an exit or entry point within 25 feet of each worker? ❑ ❑ Any noted dramatic dip in bedrock? ❑ ❑ Spoils,tools.Equipment>2 feet from excavation edge? ❑ ❑ Short term excavation <24 hours)? ❑ ❑ Are barricades Iflagging in ace? ❑ ❑ Trench boxes certified? ❑ ❑ Is high visibility clothing being property worn? ❑ ❑ Tension cracks observed along slope top? ❑ ❑ Utilities or structuresprotected? ❑ ❑ Hydraulic shore pumped to designpressure? ❑ ❑ Underground lines exposed? --- 0 ❑ Any water seepage in excavation walls or bottom? ❑ ❑ Bracing system installed according to design? ❑ ❑ Is shoring secure? ❑ ❑ Evidence of shrinkage cracks in excavation walls? ❑ ❑ Trees,boulders,or other hazards in area? ❑ ❑ Evidence of caving or slou ing of soils? ❑ ❑ Vibration from Treffc/ ui ment bein too close? ❑ ❑ Are slopes cut at design angle of repose? ❑ ❑ ❑ ❑ NOTE:Excavations deeper than 20 feet shall have protective systems designed by a Registered Professional Engineer Observations: I hereby attest that the above conditions existed and that the items were checked or reviewed during this inspection: Competent Person Signature: