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N�xxk Ort1CT. 2272721 <br /> 58 API RECOMMENDED PRACTICE 1646 <br /> PERMIT TO WORK For Petroleum/Convenience Sites 1. 2 <br /> Worker Signatures:I have reviewed and mderstand fie conditions of this 3. 4• <br /> permit and Is altachmen5. I wit!report hazardous ovndieons or acts 5 <br /> identified on this a to su ry sor or customer re osartative. <br /> ? <br /> _.._ <br /> rX <br /> Person In Cha 17aw: - Location _ <br /> Work Order M yui~ ent 10: TimeIss led: <br /> Nearest Medical Fadlitva ne p C G9 Tme ex <br /> ' am.r <br /> Em en esme Phu re* — <br /> ❑Hot Work ❑Exeavatbn CtrecMist u17 A ❑Pre E Cheddls' 0 Confined space <br /> ❑One Cal ❑HoLstln Mans sni Ot Cha e ❑Wo k Notification {7 00e, <br /> HOT WORK PERNIII 1646 Section 13 <br /> CategDry of Work Desarbe: <br /> ❑Weldl lZ3ft:taafl_0DnIlin_q DGrindfriq ❑Sandblast ❑Otl er <br /> Which of the following sDabal precaunDns are requ <br /> ❑Insoeet lExcavaton ❑Adequate BcndrI ❑Local Rect fiers Off ❑fuel Delivery ❑Hydrocarbon solls <br /> nearby❑Vent Slacks C3 01w v haxaros II : _ <br /> Atm n: <br /> eTcvs: �� I_%LEL: Tuxt HxS: <br /> Job ConVol Contact Narre: Fire Watm Name it ap cable <br /> Has the piece of equipment or system been property isolated? S NO NIA <br /> _ O ❑ <br /> Has the energy isolation been reviewed a -Ilallectedem Dees? ❑ ❑ <br /> Ust AN Affected Workers 1. JU14 1V2 _ 3. i4, <br /> 5. 16, 18, 5. <br /> TRENCHING AND EXCAVATION—API 1646 Section 9 <br /> Has*One Call'performed ufllty mark outs? YES N0 One Cal Dig Number: <br /> ❑ C <br /> Hasa line_localfn�service marked out utilities on-site? ❑ C Comments: <br /> Weather Cendltlons: Rainfall Last 24 h a er dndib ms: CTWeT-U Dr <br /> Who k the utast sled a Com t Person? -— -- How cee is dime_xuava+ion? <br /> Manual me*,nds tD determine sa! umb Compression Test ❑ ❑Plasl,ty ❑Dry Strergth <br /> classification: meter <br /> Visual mellhocls to determine s0i! :' ❑ bsery mples ca <br /> of excavated Observaexceiva' ❑Observe adjacent ❑Ouserye sal as d is <br /> classification: / matrial walls surface area excavated <br /> Trench+Excavaton MeasureLength: W <br /> Depth: <br /> if;-OIL also complete as cation Permtt <br /> What is the W Classf alion ❑Alable Rock'v ❑ ..14:1 Class B 1:1 ❑Gass C 1.5:1 <br /> Which otectve s. . s ? JOSI in ❑Sh ❑Trepolin sinaidrrrench Box <br /> Are Employees Kepl Out d c w away'rem 11on ES NO vide ce, rca ; dire planes in soil or mdo YES NO <br /> du' digging or materia ndli ? ❑ ❑ ❑ Q <br /> Neva er ratific_et_ions tilien made? Z ❑ ❑Y Any area of unusually ' ❑ ❑ <br /> Is here an axil or t within 25 f of ea worker ❑ Anot d ?. 0 <br /> Spoils,kxAs.Equipment>2 feet from cavation edge? C3 Sha exaonX24 hours` ❑ <br /> ,rnAre barricades/ In aoa� [3 xvis ❑ ❑ <br /> Is hi vWbili do bei worn? 13 Te ion aolonD ? ❑ 13ruoeJHlreor structures rot H c ❑❑ <br /> d n preI Q ❑ <br /> Underground fines axpo24Z Ahy water vation walls or bottom? ❑ ❑ <br /> _Bracj.asyMem ristallacj§por6ng to desi ? ❑ Is shorinn secure? ❑ ❑ <br /> Evidence of shriMm a ffacKs In excaveidor+waft? _ ❑ 'rrees,boulders,or other hazarus in area? ❑ Q <br /> Evidence of Cjvinq or sloughing of saris? ❑ ❑ Vibration.kom T ralfc! woment being tou Buse? ❑ ❑ <br /> Are slopes cut at design angle of n, ? D ❑ _ ❑ ❑ <br /> NOTE;Excevedons deeper then 20 feet shall have protectIve systems designed b a R istered ProfaetrfOuref Erl h1#W <br /> Obaenraltons: <br /> !hereby attest that the above condRfars i;4o.-d and that the!ems we a ahockad cr reviewed thrrtllg this i uaecfof' . <br /> Corn nt Person Signahi <br /> Tanknology Inc. 11000 N.MoPac Expressway,Suite 500,Austin,Texas 78759 <br />