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0 SAFE WORK PRACTICES FOR CONTRACTORS WORKING AT RETAIL PETROLEUM/CONVENIENCE FACILITIES 59 PERMIT TO WORK For Petroleum/Convenience Sites Continued 1��,HOISTING AND LIFTING—API 1646SOCtion 10 Has the Lift Plan been completed by a competent person? YESNO Does the equipment have the size,load,and swing YES NO ❑ ❑ capacitv to do the job safe) . ❑ ❑ Air or hydraulic systems inspected for deterioration or leakage ❑ ❑ Tool Box discussion conducted&lift plan communicated ❑ ❑ in lines,tanks,valves,drain pumps,etc? to all affectedpersonnel? Hooks,hoist chains,and end connections checked for signs of ❑ ❑ Are outriggers set before hoisting operations NIA wear,twist,cracks,distorted links,or excessive stretch I b in? ❑ ❑ ❑ Has rigging been performed b a competentperson? ❑ ❑ 1 Is Droper cribbing being used ❑ ❑ ❑ Is the hoisting equipment sidin on a stable surface? ❑ ❑ Overhead risks evaluated as Iart of the lift Ian? ❑ ❑ ❑ Is work area property barricaded/isolated? ❑ ❑ Is the operator certified for the equipment? ❑ ❑ Has the hoisting equipment been inspected before use? ❑ ❑ Are periodic inspections complete and documented? ❑ ❑ Atmospheric Tests(Pre- Time: 02 %LEL Toxicity Isolation&Ventilation 19.5%-23.5%: <10%: 192S,Benzene: Source IsolationElectrical LOTO ❑YES 13NO 11 NA (No Entry) Pum s off&LOTO ❑YES ❑NO ❑NA Lines Disconnected ❑YES ❑NO ❑NA Valves shut and LOTO ❑YES ❑NO ❑NA Note:If an "NO"is checked above,fill out'Permit R ufred Confined Space Entry Permit'section. Nall"YES"or"NA"Continue on. Atmosphere Mechanical Forced Air ❑YES ❑NO ❑NA ventilation: Natural Ventilation Onl ❑YES ❑NO ❑NA Atmospheric Tests(Post4solation Time: 02 %LEL Toxicity &Ventilation1(19.50/-23.5%): II00%: H2S,Benzene: Pre- Surrounding Area Free of Hazards? ❑YES ❑NO ❑NA Entry Proper notifications made? ❑YES ❑NO ❑NA Check Does your knowledge indicate the area will remain free of all ❑YES ❑NO ❑NA List atmospheric hazards? Are you trained in confined space entry? ❑YES ❑NO ❑NA Are you trained in the operation of the air monitor used? ❑YES ❑NO ❑NA Has the monitor been calibrated before use? ❑YES ❑NO ❑NA Did you test the atmos here in the space before entry? ❑YES ❑NO ❑NA Did the atmosphere check as acre table? ❑YES ❑NO 13 NA Will the atmosphere be continuous) monitored? ❑YES E3 NO ❑NA NOTE:IF ANY OF THE ABOVE ANSWERS ARE"NO",DO NOT ENTER CONFINED SPACE ENTRY PERMR—API 1646 Section 11-: ."4n Purpose of Ent Ent Su ervisor: Attendants: 1. 2. Entrants: 1. 2. 3. 4. 3. 4. Pre-Entry Checks: ❑LOTO ❑Emergency Rescue Plan ❑Secure Area ❑Ventilation ❑PPE ❑Lines Isolated@locked ❑Res irators ❑Fire Extin uisher ❑Pu a ❑Hot Work Permit ❑Communication s stem ❑Lighting ❑PPE ❑Lines Isolated/blocked ❑Respirators ❑Fire Extinguisher Minimum Re uirements To Be Completed&Reviewed Before Entry Continuous Test PEL Initials Time: Time: Time: Time: Time: atmosphere 0 en 19.5°/a-23.5% Valve: Value: Value: Value: Value: Monitoring: LEL 10% value: Value: Value: Value: Value: (Record at least H2S <10 PPM Value: Value: Value: Value: Value: every 30 minutes) Other Value: IValue: Value: Value: Value: Remarks: Gas Tester Make/Model: I Instrument Serial Number: Have all of the conditions above been satisfied? YES O INO❑ Attendant signature: I Entry Supervisor Signature: I ensure this permit has been filled out completely and in conjunction with all applicable OSHA requirements to provide a safe workplace for all workers and myself. I will take action to eliminate hazardous conditions or acts Identified on this job site. Person In Charge Signature.,