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t i i i I 50 API REcoMMENoEo PRAc ncE 1040 V— PERMIT TO WORK For PetroleumiConvenience Sites 11,41g v x 2. Worker Signatures:I have revrevred and understand the conditions of this 3 4, permit and its attachments. I will report hazardous conditions oracts identified on this obsite to my supervisor or customer re resentative. 7. 6, 9. 10. - --- - { Person In Char e: _L% _.' Date: C%- Z 3-Ur Location T Work Order# /G•9/1;1 _ �TE i meet[D: Time!ssued: Nearest Medical Facility&hone 4 _ _ _ _ Tima expires: am!m Freer en /Rescue Phone#- - - - s 6. ❑Hot Wcrk i ❑t ❑Pre EnV Cheddist` ❑Confined S ace I❑One Call ILI HolslinagallnU Q Management Of Chan e ❑Work'Nottficatfon ❑Other { Category ofWgrk describe:" ❑Welding ❑Cutting ❑Drilling ❑Qinding Q Sandblast ❑Other Which of the(clawing special precautions are required? Check all that apply. t ❑Inspect Excavation ❑Adequate Bonding ❑Local Rectifiers OffLock-Out Tag-Out ❑Fuel Delivery 12 Hydrocarbon soils nearby❑Vent Stacks_❑Othervaoorhazanfs :fist: Atmospheric Tests: Oz: %LEL: Toxicity(Hzs): Job Controf Contact Name: Fire Watch Name if ap Icabie) - I Has the piece of equipment or system been property isolated? YES NO NSA Has the ener [solation been reviewed b ail affected employees? ❑ _ ❑ _ I List Ali Affected Workers:1 1. 12. 3. 4. Has"One Call"performed utility mark outs? YES !O one Call Dig Number: 0 ❑ Has a line locaUN service marked out utilities on-site? Q El Comments: z Weather Conditions; Ralydall Last 24 hours? I Water Condillons: ❑Wet 13 Dry Who is the designated excavation Competent Person? Hcw deep is the excavation? Manual methods to determine soil ❑Thumb Compression Test ❑Pocket Q Plasticity ❑DryShri* 1 classitrcatlon. Penetrometer Visual methods to determine soil ❑Observe samples of excavated 13 Observe excavation ❑Observe adjacent ❑Observe soli as R is i classification: material walls _ _ surface area excavated_ Trench/Excavation Measurements: Length: Width: Depth; if>4ft.also comp tete reset lreclassi icatlon Permlt _ What is the Soil all 1103 Class A 3/4:1 ❑Class B 1:1 ❑Class C 1.5:1 ! Which protective tem s is used? 113 Sloping ❑ rinq ❑Trench Shiewirrench Box ( I Are Employees Kept Out of and/or away from the excavation YES NO Evidence of s'nificant fracture planes in soil or rock? YES NO durbig digging cr material handling? ❑ 13 O 13 Have proper neGficaf ons been made? ❑ ❑ urea of un sually weak sails or materials? ❑ ❑ Is there an axil or entry point within 25 feet of each worker? ❑ 0 Any noted dramatic dip in bedrock? Q Q S arils,tools.Equipment>2 feet from excavation edge? ❑ C3Short term excavation(<24 hours)? _ ❑ ❑ Are barricades J flagging in lace? ❑ ❑J Trench boxes certified? ❑ ❑ I Is high visIbility,clothing being o wom? 17 ❑ Tension cracks observed a1 sloe top? ❑ ❑ Utilit es or structures protecleV ❑ ❑ Hydraulic shore pumped to designpressure? ❑ ❑ Underground lines exposed? ❑ Q Any water see a e,in excavation walls or bottom? ❑ ❑ Bracin s stem Installed accordin to desi n? ❑ ❑ Is shorin secure? El Q Evidence of shrinkage cracks in excavation wells?- ❑ ❑ Tres boulders,or other hazards in area? ___ ❑ ❑ f Evidence of cavi or sloughing of solls? E3 13 Vibration from Traffic/e uioment beingtoo close? ❑ ❑ .Areslo ascutatde'nae leofre ose? Cl ❑ _CI ❑ NOTE:Excavations dee er than 20 feet shall have protective systems deslgned by a Registered Professional Engineer Observations_ !hereb attest that the above conditions exWedand tot the items wore chocked orreviewed du»n (his ins ecBon. Com tent Person Signature:. L su-t j t t r