|
_ .. -. .:. ..¢': .., 3 � d%o cr .:»�:.r. �,:�,• ,. :; _ _ a-a�,... .. .. � • _:». :,r , � .ii'Fr- 'sem. ..�� "� , : �. ��'^�' , �- , e s�-.�`a."}a^r`��.r+ ti -� • �� '.. ix'�� �-n- ��- � _
<br />�::�- .:.<.. -"... y .,_ ,,,;•,.-��..,• ,. b. zacve... -vim. ..t�<...�"�"u - ;,.r:. °��:.,.:,sb-cm-F.. .:: 'k� '�,,., c �.-.s:. �" ::�. .:�§r,�.�'�«> z',-.�,�.r �, ;t �� �,�- .,t.... �-:a-
<br />�:-•"� �' .--i-'i.��-u .,�..-:> .�.,��'�-`": 't �,�+t'.:� .,Ml-�--r-
<br />3, 9 iy„',, �. a. �� _ - - � '�'� � �' tt-w�:r�tt��" �a"`�,F' a �✓;' w. �v J sf
<br />ASAP #. » Address: Date:
<br />CRA Field Leader Name and Signature: _ -_ # of Site Workers: JSA Name:
<br />Start Time: End Date: End Time Required PPE will be lasted in the SA
<br />Start Date � J
<br />.. _,c IM.,
<br />; ..> ... ..,
<br />u U ty h
<br />:��5,"'v..",.h SA
<br />., r, w. _ a.. .. .:• � <'.. ""� ..;. �.. µ`1 . ,.. � ,r�`.�.,,-. ,. •.,w. 'fi' r i Y:a ��.._ , .,K r t � :.2x. s ':: y a, -;,M...;
<br />�ci .
<br />-
<br />Task Step Hazard Not Covered by JSA Steps Needed to Mitigate hazard (including PPE)
<br />%;
<br />�ftSi�
<br />❑ Work >6 ft above grade ❑ Look Out/Tag Out of Energized Systems ❑Confined Space Entry
<br />❑ Trenching/Excavation >4 it below grade ❑ Hot Work( within 35 ft of USTs, dispensers, or vent ❑Cranes and/or Rigging
<br />stack, Welding, Grinding, Cutting Metal)
<br />A special permit to work will be required for any of these high-risk activities The special permit to work will accompany this fob clearance form
<br />6
<br />k t 5
<br />.'. �^
<br />} Sign.in _ CloseC3ui
<br />Site Representative " Signature: Site Representative: Signature:
<br />Signature: CRA Field Leader Issuer: Signature:
<br />CRA Field Leader ';".. � r g -�_
<br />El. Have all site personnel been informed of work tasks and hazards? , ' Has work area been cleaned and restored to original condition?
<br />Has fuel delivery service been informed? t Are there any conditions requiring notification of station personnel?
<br />Will fuel be delivered during work hours? ` Have all unsafe conditions, near losses and incidents been reported? ,
<br />Are work areas cordoned off to protect workers, staff and the public? Other Comments:
<br />Are any high risk tasks planned that require a permit to work?
<br />-.�., ,*:'. �' ..,,. -.i. ,,-«a. x 'se- g.,. ,�� : *�.. . ss.- t '.',� ..,...x?..>�. � n ���n�ti-.. : � .a-^sa.%: ?7r�^•^,.y3..,�°�',.�.�'.:,»��^;_;.' .-.n'a^. y'd,-tr..»�r`�' u— '": �...�...., ,�5-�« - .`ar.n-,.�rcr�.:a<`"�.�� + ._-.usA,.V�;'.:m..-z,..sF�::'_, x_ r.,txtt,; ,terd_,; �,. >:r_rir,k`.e..°„. M .� �
<br />�� r.:.>.;s: ,�3.,a. ..:az.:.,*.,E•,_.r�.x+vtea. r"g'+'
<br />n".�,.sa�
<br />.. ..:..� x.... ... ...: ': '�' ��v;.:... ri , a �x'z.. _..... . 'air �,a. _i�:. '� ..:, `�'- ,',.�,- `':f ...:Y» '� d.'_ `�'"�v �,.” •^a �
<br />.-.. _ "a ._..: ,:.: �a, .a...: asr..... z�� �,c:..c.'r "� ..: •. may,.-,,., Pr..,' .. ., .. : . T4 ..:a r :.,,. ✓ �'k !.Jn. ..`,3� - �. _. _.. ...� .. n'. `':a
<br />e:� F- Y ., ^xc�.__ _,,: /n:.- � .z z .:"--.. :.,s.�. "� �.e.•+.-.«�,.. ,r v �..:,_. e:...».� r<.rzo-4 .__.........., �v .x,�. ws�nr. F . Vis. �m:.w.,,.,...� >�.�a . �."s -_
<br />• ♦ -
<br />
|