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ClearanceJob Form <br /> Station d: Station P,ddress: Work Ur er Numner: Date: <br /> r60.ort•actur�rrgatt�ryy Nam- antracmr oersoncl,+ry.lprlrtranr: ern etc - - _ <br /> AiMeRhce NYrtl6v: Start-Im. LnJ lln,r. der, cc <br /> P. <br /> L a�i1 <br /> n <br /> - .... — <br /> ... - _... ..._. t—CA. Yes/Na oor <br /> rA <br /> Sts <br /> Y, <br /> Yet;V. W <br /> C <br /> ;AF ETV`/F57 HARO,Ini JES B600TS - <br /> HEA0.ING FRO7F,-710a1 <br /> TLC WE CLOTHING LL7YT5 sAFET'r:,1 ASSF <br /> WELLING PIPE DOTHCR in <br /> N <br /> Shp -..Har�rds�vt rouvad by Jill <br /> -._. ..."F�41710 t0OdCl0[2Mtlkrats Auk•1nrluM?P`_ly L,erl(oht T <br /> N <br /> N <br /> tU <br /> L <br /> a. <br /> x <br /> w <br /> U <br /> -� f0 <br /> YyurkdwYmmtasan-equl•e•nen:. lower Nuk-no.)SArequlmd Medlum Rlsk/NIoherWktas4s-1SAnyuked Hlelsa Rua-ISAnqul.Warapprowiale check Rsl completed(web ,C <br /> ,Examples ofKJgher/Medium tasks: ❑ Works athe,ghtclnallca—onopenill -oncbsedSiteslfnolSAPresent ❑ Work LrwArkscAspacn(e.gtanknterceptor«craps whal{miry) ZG <br /> IDTrmdsipaeacays:bn refar.Y.•n urdr,grormd tank product p­ E] Hoturotkwlthrlsk orpmductofa.prsw4l hlon O <br /> O <br /> ❑ Haaxy litttnq ❑ LPG ryNen,degaasllty lru411atfon or maintenance O <br /> CtsMracmr•eorcsen4r'•x n.m• sgnaturelfIlN)PjTV!Ffl� ContRmrslgnaturc U <br /> Operating Mello be Signed by the Site Represenradve i GENERAL SAY CHECKS <br /> - � <br /> Nobpc rating Sites to he ngne6 by Cotnracmr Represers4tive pnly FELA <br /> Hn N wal aRa Iwn Ln tray and rah) <br /> Ob <br /> GENERAL SAFETY CHECKS •Are ak oenom{I ar ah,>7 ran.,dwork - <br /> -g-01.1re R,xanel bin InIn-W. nnar.y habnrmr <br /> -ps4larR,R 514 representame name signature -Aro den.a b equip—t d­—W <br /> ry rrrvee Oen u-,6rrMT � <br /> mmmunh{rrdT S:x vpresenfatAre tante Signature <br /> -n.n,..a.nery duel ,�°.,c..,,. -- .� �'�"I' }'n r� r?•� rc,acne Ker .«t,.,..s.ar....a., ��j 1 'l /! � <br /> -Nm hoihm Pmreaves lrenNHed-lova�-l:aa uu,7 1 Ia.... � �� Ot '���Y',V Y��/ G �• I--' <br /> V Y -Cd,N <br /> N -A2 work areaxc:NakedMmproL twnhen.,ne mR{p,r.,e.> t Sitere memetivacommeMs <br /> � <br /> PARTS-Ordered,Replaced andlorDisposed Of(include model and serial 05asappofpriate► <br /> -- <br /> N <br /> Tnecorri-mr through ht auihorlled represantallae shad <br /> sign hsue and bei responsible for m al Job ckvrarceforms and[he ob lgatbns arlsingt re under appllcabkWthe work. <br /> This form corers important nminden mtl Ts nor lmenied repave the contractor from safely pedorming t he mdk In cc mp,'.ance rn:h all applicable laws and regulations <br /> � I The store eperatcr Kay requee the contractor msmp wcrkdl[aopeen thet Mecontr{cmroNny of its workrs ara(allnq to comply with lne moulRreents In the applicable lRms arthbf nnwolher applicable safety rcqulremercs <br /> 1 <br /> 3 <br />