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M <br />M <br />d <br />R <br />IdlO <br />10 <br />GO <br />N <br />ti <br />Cal <br />O <br />N <br />ti <br />0 <br />t - <br />N <br />T <br />/a <br />3 <br />N <br />tB <br />!/Y <br />.. Clearance <br />Form <br />CONTR4CMIYBTRUCTOSPA03TDSTARr OFWORIC T. RevieAfomy Clackappmpiale boxes, read andsVign at the bo" of Nmlis k <br />i. r"des`er, Mrggw CrreMmtabw bills job to bepelremYdand pmenliatsafelymn emsard&UP 5191131ure <br />Stall/ p Siasm Address i'i-, :- 'T ..,r .^� [[��,:,: ` C -"^-r <br />Work Order Number: �.. � .�E <br />Date: <br />Conaa0arCo,tparorName; crabdperm ancarr hmanamel; rOVANAre: <br />JSAR-imme Number. StdTiaw: Esdmme <br />Lagar' Tappet Ing: Travel Cleave: <br />Oraqviiadi <br />Proixenv'Pfolk Qeser+•nllan: = 1 A ir-�.s'-+j J ,•+'}.' <br />f'•';f-�r•� •�f>>. �� /+` ,.',�'".' <br />F <br />r' <br />+.3' 1 - /fir• <br />Return Call yes 1nD <br />Damage Claim: yes) no <br />.Q SAFETY VEST HARD HAT 13SHOEW8007S ❑ HEARING PROTErrON El RESPIRATOR <br />❑ PROTECTIVE CLOTHING 0- GLOVES Q -SAFETY GLASSES/GOGGLES ❑ FIRE RESIST CLOTHIMNIELDING PPE ❑ OTHER <br />circuunslances on silo or specific to this job may generate addilionalhazards not(lesclibed in tl,�JSA <br />(please, use ba& ol page hadditionAl spzce,s ragweed to document) <br />Task Step Hazards Not Covered by JSA Howto reduce or eliminate risk include extra PPE to he vain <br />t- ... /�,Jf.... <br />------------- ____ ____ �.___.___' _ <br />-__ _ .'_:'�..I l <br />__..: 1'" :.:...... ..... ......... �.___ _.____._.__. --r_..._ ___. ...___fir __ ___.___ -----------�_._._. <br />_ <br /><---- .�_F__h___.'J__f.___-_._,_1_'___ <br />i <br />I.ei-_''•!� .?�r___.._� •-'-.! - .�r�- .._..__. <br />-- - <br />___..,_'._..I'I.J_______________ <br />_______________________---------------------------------------------__________________ <br />__ <br />__ _____________ i._____-.______ <br />--------------- <br />Work oocumenmtlan eequirements Lnwer Risk—Th1treemmaybeusedas JSA Medium RlsWHiahm Rlek—JSARequtred Higher Risit- J8A Requlredand other customer requirements may apply <br />Examples of hloher/medlum Risk Tasks ❑ Works at heights <br />❑ Work in confined spaces (ex- Tank, interceptor, or manhole enW <br />❑ Trenching or excavating <br />El Hot Work <br />❑ Hoisting/Ftigging/Heavy Lining <br />❑ LPG system degassing, Installation or mairaenanoe <br />Contractor represemallve name i Signature <br />• .. • - • • • • • • • Contractor signature <br />Operdbrg saes:W bB dgned byline site replasenlibve ,l--///,�'.� <br />-'f <br />aems the ScA ave been 10 BY Cand SO rnR �_M1 <br />•Inas Ne•,vcvlc arse been leg Idly sa'e. ,.— <br />NapWeralingsNes: to bes'gned byUnbana �''�' .ry,,;il <br />• Is the site aperdlaranueorstelus cdAwkindudrgam remaorgisslabm? <br />reyresema0•ecNf <br />CONraclwrospma'6illlyroinfwrnsAenl: Site represent alWe name Sl�alura <br />•mceageseaequipmen! Site representative name Signature <br />Fna g <br />++mersedarAwmat.hwled? <br />. HaTaldsoflhe ContraGtorhas dbcus JobCtearanwFormTMdtme <br />• FII inddmis, nearIrieses,enfala 'l <br />• Eflests engle s@e oroA:raion. -�:=J _ /' ,- r t <br />• Anyaifect logesolins derwehes, !?,,ir. 1 <br />situalans <br />tilt* Co anis• <br />,f_a-, ., <br />�./ f t <br />reoreseataave <br />• Energy boleGon needed, /!� .1 -i. , t.,:E <br />._--------------- ---------------------- <br />e Argas to be barTkaded loraorkerlpublic safely. <br />^-• <br />............................_____-_---__-_________..-_______.___-__._.__ea.-____..-_____. <br />._......._._ <br />PARTS - Omamd, replacedariftrdlaposed W (htclude model and serial m mbere as appropriate) <br />The antraclor through cos autlxT®d representative shall sign, ism and be sielyresporlslbW Wall Job clearance norms ano Ina angawns anung slang arcv, OYP'rguicw viv ru,n <br />This kern covers Important reminders and is notintended to mFm the contradorYem safely pedorming the work in catepliance wiihappfrabh Imus and regulations <br />The site operator may require tie wnbacbTrto slap work if it appears dlatlhe conbactoraratryaf its lrolkers are falling to complywith he requirements N the applicable Items of Ihisform arolher applicabla salaly requirements <br />WHITE SSSfABLE OFFICE COPY YELLOW: SEND WITH INVOICE PINK: LEAVE ON SITE <br />