Laserfiche WebLink
CONTRACTCRWSTRUCTIONS PRIORTO STAR'OF WcRK: 1.Review tomt,check appropriate bones•read and sign at the hoaorn of this form 2.Inform dealer;manager or representative of the fob to be penormed and potential safaty concerns and Main signahae <br /> Station#f,�� � Statlon Address - - Work Order Number. <br /> _ S' �./s 1 r` ' /If ,?o? 'r C ' i e �e> Dace: <br /> Contrac;u company Name: Coniad perwn n charge Via namak •W s:r• Ntm6erAA Rekrence Number. StattTina Flyd Tlinr~ Lseor. TrevW Tkre: Travel gpanrp: <br /> .�f-' I iiia nod -'� <br /> ProblernMlork Desc iption: S•,� •?J 95.9 <br /> /�r i''�//75- "7 <br /> Return Call' yes/no <br /> Damage Clairn: Yes l no <br /> .•�.. .. n -o.• w' as a ., _ '.r <br /> SAFFTY VEST HARD HAT SHOESJDOOTS Lj HEARING PROTECTION "�RESPIRATOR <br /> El PROTECTIVE CLOTMNO QGLOVES .SAFETY GLASSLSIQOGGLES ARE RESIST CLOTHING/WELDING PPE OTHER <br /> Task <br /> J r Task Ste Hazards Not Covered <br /> _.. ---- , -•--....----1.=--•-x=';r _ --------- b JSA . <br /> P t°r••c-f^er eliminate risk <br /> - <br /> ! <br /> include extra PPE to be worn <br /> -- --^.._` '----- <br /> zf � G ---------- ----------- <br /> . „i � <br /> --- -- - -• -------------------------------------------------------- <br /> -- ----- ----- - ---------------------------------- --------------- -------------------•------'--- - <br /> Wornc documentation requlromenfs _Th(s faro map ba used ay JSA fL"um Risk"oher Risk-JSA Required Htnher Risk-JSA Required and other Customer requirements may apply <br /> Examoies of hfaher/medium Risk Tom []Works at heights ❑Work in confined Spaces lex Tank,intoiceptor,or manhole entry) <br /> El Trenching or excavating ❑Hot Work <br /> (]Hoisting/RiggiVHeavv Lifting []LPG system degassing,Installation or maintenance <br /> zi <br /> Contractor nepresenWsve name Signature • r •• •• . •� • Contractor signature <br /> OperaNr>g sites:to he signed b the site representative GEIMRAL SAFEW CHECKS ay coNTRACTOR <br /> Non-operating sites:to be signed by Curt ac:cr �)/�'� 9%y�Lf v iS � .�y •Has the work area been lee tidy and safe? IT <br /> •Is the site .�,�. <br /> nifty to inform <br /> re sionite <br /> operalor aware cf$latus of work kr.Iudiing any remaining isolation? <br /> ConkaclwresponsbLMbinformsteoE Site representative name Signature -Are changesioaquipment Sites( resentativename Sfgnadxe <br /> • Hazer&of the job, donrnenled and commun cased? <br /> • Effects on the site or operation, •AV Widents,near misses,unsate <br /> • <br /> Any affecttogasoliladeltvanes, t <br /> 1 smlalia'areported? <br /> • <br /> Energy isoladonneeded, r ., tr,yi lLt �jlyn ese tiv en '. <br /> • Areas to be banlgdedforworkwicublicsarety- ----- ------------------- - - --------_._----_ --- _- <br /> PARTS-Orde nep/tacwd and/wJJldlsposed of'(in elude model and seriat numbers as approlprim) 17 <br /> ---._- 7'T ^ V ICr.I�.L�' A.f d a�. /�/l /1, �i� 1-•/^Y� M -The contractor through its authorized representative shall sign,Issue and be solely responsible torah Joh Clearance Florins and the obligations aifsin hereunder a��aWe to the work <br /> -- — — Y <br /> This form covers Important reminders and is not intended to relieve the contractor frm osafaly performing the work in compliance with applicable laws and regulations <br /> The site operator may require the contractor to stop work if it appears tot the contractor or any of its workers are falling to comply with the requirements in the applicable items of this farm or other applicable safety reguiremerils <br />