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Job Clearance Form <br /> Contractor Instructions Prior to start of work: 1.Review form,check appropriate boxes,read and sign at the bottom of this forth 2.Inform dealer,manVer or representative of the job to be performed and potential safety concerns and obtaln sl nature <br /> Station k StgVdres ��`iK <br /> 19 �P^.� r Nu j der:� Date: -L-- <br /> T--- <br /> �_ <br /> Contractor Co act Parson in Charge(Print Name) Number of "1 JSA Number: Start Time. End Time: Labor L Travel Time: Travel Miler. <br /> company Name: Gettler Ryan Inc Workers <br /> ProblerNWorkDescription: t�\�dl► ��ac �� � �1�� pp(Z� <br /> F�'1L��.�-��Ca •�^ � Y � `.��� ����� Return Call: Yes/No <br /> Damage Claim: Yes/No <br /> PPE Required(check all that apply and/or fill in"other"blank space <br /> Safety Vest ❑ Hard Hat Shoe&S is <br /> 7V ❑ Hearing Protection Respirator <br /> Protective Clothing nal Gloves Safe Glasses/ les ❑ Fire Resist Clothin Nyeldin PPE Other <br /> (pleaseContractor to complete section below if circumstances on site or specific to this job may generate additional hazards not described in the JSA <br /> back of•..- if additional space -• -• •document) <br /> Task Step Hazards Not Covered b JSA How to reduce or eliminate risk-include extra PPE to be worn <br /> •2 f t�i -' <br /> Work 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 <br /> Examples of Higher/Medium Risk Tasks ❑ Works at heights ❑ Work in confined spaces(ex.Tank,interceptor,or manhole entry) <br /> ❑ Trenching or excavating ❑ Hot Work <br /> ❑ <br /> Hoisting/Rigging/Heavy Uffi g LPG system degassing,installation or maintenance <br /> •- . •MWO1141iii1l•. . ... - • .PA -. .- • <br /> contractor representative name St nat • • • • • • • • ctor Si nature <br /> operating sites:to be signed by the site representative Non-operating 7Gene�ralSafety Checks By Contractorsites:to be signed by thecontractor representative Only Has the work area been left tidy and safe? <br /> Contractor responsibility to inform site of: Is the site operator aware of the status of work including any remaining isolation? <br /> 0 Hazards of the job, site reresentative name Si nature Are Changes to equipment ISile-Replesentative Name S' na re <br /> 0 Effects on the site or operation. Co dor has d'Iscusssd JoIxCleArance Forth with me documentation and communicatiun? <br /> 0 Any affect to gasoline deliveries, 0 All incidents,near misses,unsafe <br /> 0 Energy isolation needed, situations reported? <br /> 0 Areas to be barricaded for worker/public safety. Site representative comments: <br /> Parts Ordered,replaced and/or disposed of include model and serial numbers as appropriate) <br /> 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 work <br /> The farm covers important reminders and is not intended to receive the contractor from safely performing the work in compliance with applicable laws and regulations <br /> 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 forth or other applicable safety regwrernonts <br />