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Conitat ;,r Instructions Prior to st•trt of work ' W.y,r:v 6 em M:i{r,n.{in i!. C .•'s r.•d,ind-in at the W,ltom of this for in 2 Inform dueler"kanaWr of re re Sent ative of the J[,to be perlornriO and potonhal safety conrxrns and obtain signal—
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<br /> o t r .a u,"'w k• t h.u•.. .,t,.•, I L JSA Nvr.oer S End Tune labor TrevW Tian Travel Myles
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<br /> Problen A,rk Oe,.n{! n f7-1 5 - Return Call Yes 1 No
<br /> Damage Claim- Yes t No
<br /> safwy Veil ❑ Hard Hat Shoes Boots ❑ Hearing Protection ❑ Respirator
<br /> ❑ Prolnclwe Clolhtnq ❑ Gkrves Safety Gla&%e4Goggles ❑ Fire Resist ClolhmgMetding PPE ❑ Other
<br /> Task Step Hazards Not Covered by JSA How to reduce or eliminate risk-indude extra PPE to be wom
<br /> Work documentation requirements Lower Risk-Th s form may be used as JSA Medium Risk/Higher Risk-JSA required Higher Risk-JSA Required and other customer requirements may apply
<br /> Examples of H!(ther'Medium Risk Tasks ❑ Works at heights ❑ Work In confined spaces(ex Tank,interceptor,or manhole entry)
<br /> ❑ Trenching or excavating ❑ Hot Work
<br /> ❑ Hoisting/Rigging/Heavy Lifting ❑ LPGs stem degassing. installation or maintenance
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<br /> General Safety Ches By Contractor
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<br /> Contractor responsibility to inform site of O is the site oper.e ay.ary d nti,tams or Mti miu0rrq any rermmnrn9 aaww ,,
<br /> y Hd.:ards of itie iot) •,nr,,, r.vnt.a v„muni S nelutu 0 are Ct•4r ms to equ pmunt
<br /> Site ReVesentative Name nor
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