COMPLIANCE INFO_2013 - 2018 - Laserfiche WebLink

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Job Clearance Form CONTRACTOR INSTRUCTIONS PRIOR TO START OF WORK: 1.Review form,check appropriate boxes,read and sign at the bottom of this form 2.Inform dealer,manager or representative of the Job to be performed and potential safety concerns and obtain signature -'T Work Order Number. Date: Station,#:x ~L! .c t Station Address: f(,[ L .1 r (�!;�•°� t ri 1 ►A i. ;Wffltacr CompanyName:{ Conal person In Charge(print name): Numbed orkers: JSA Reference Number. Start Ttrne: End Time: Labor. TravelTme: Travel Dista rce: .. N� r' P ifreitblern/Wor Description: ( r' �?• t�. ;<•�Y.�= �" ► max, >r l- s ,�- .._;: Return Call: yesIno ti Damage Claim: yes/no rSAFETY VEST HARD HAT HOES/BOOTS HEARING PROTECTION RESPIRATOR ATECTIVE CLOTHING -GLOVES ❑SAFETY GLASSES/GOGGLES ❑FIRE RESIST CLOTHING/WELDING PPE ❑OTHER T sk Step •Hazards Not Covered by JSA How to reduce or eliminate risk-in extra PPE to be worn r� - , .•fir_'_Y.1 ty •'` t(J kr - - ---------- - ---------------- - ------------------ 4----- --- ------ { ------ .-----1--- --------- -- ` -------- ` ' 1. - - - ------------------------------------------ -------- -------------------------- -'21,'- - - _ _`=a-------_! ---- --- -------. s = _t_a------------------------------- 4 ♦ --T - ____ tajrork documentation requirements Lower Risk-This form may be used as JSA Medium Risk/Higher Risk-JSA Required Higher Risk-JSA Required and other customer requirements may apply ❑ El in confined spaces(ex.Tank,interceptor,or manhole entry) Examples of higher/medium Risk Tasks Works at heights ❑Trenching or excavating ❑Hot Work ❑ Hoisting/Rigging/Heavy Lifting ❑LPG system degassing,installation or maintenance ♦ .. i L .• om ONO Ml Contractor representative name Sfgn,ture • • • •• •• • • •• Contrgctor,st'gnature !', GENERAL SAFETY CHECKS BY CONTRACTOR � Operating sties:to be signed by the site fepresenladve �• f . "'• • f' i'YA- Oper g M,••„ .' Has the work area been,loll tidy and safe? i� r: ,--•�•�,�.- /; r.. p •• Non-operating sites:lo be signed by Contractor ;t ,�.,,.s. Lk•"t 'ice'ti T •Is the ske operator aws of status of work Including arty remaining isolation? o representative only ✓' -Are chahiles,idequipmenl Site representative name Signature f j' Contractor responsibility to inform site of: Site representative name Signature documented and communicated? • Hazards of the b, •All Incidents,near misses,unsafe • Effects on the site or operation, (' r t�( situations reported? l�?1��Y�1 1 '�4'i l��"� f. t 7 =`► • Any affect to gasoline deliveries, C'`�. ``•, } t 7 Site representative comments: - ��I:��..1t; 1 Lit, r' •v. �' --------------•------- 11 • Energy isolation needed. - - - - - - • Areas to be barricaded for worker/public safety. -_- -- --—_._. _ --- -- ----- - --- ---- -r PARTS-Ordered,replaced andJor disposed of(include model and serial numbers as appropriate) �.. -- - _ ---------- ------------------_— _—_ --- -- - - - ---�—t---4' -__---- - --- - —_ __ _ -------- o -------------=- - --— -- ---— i` The contractor through its authorized representative shall sign,issue and be solely responsible+for all Job Clearance Forms and the obligations arising there under applicable to the work This form covers important reminders and is not intended to relieve the contractor from safely performing the work in compliance with applicable laws and regulatlons The site operator may require the contractor to stop work if it appears that the contractor or any of its workers are failing to comply with the requirements in the applicable Items of this form or,other applicable safety requirements u,urTr.cccrnnr c nrchrg rnoV VFI I nW.SFNO WITH INVOICE PINK:LEAVE ON SITE