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SAP M Address: Date: <br />CRA Field Leader Name and Signature: # of Site Workers: JSA Name- <br />Start Date: StartTime: End Date: End Time: Required PPE will be listed in the JSA. <br />Task Step Hazard Not Covered by JSA Steps Needed to Mitigate Hazard (Including PPE) <br />❑ Work >6 ft aboverade <br />g ❑Lock Oui/Tag Out of Energized Systems: ❑Confined Space Entry <br />❑ Trenching/Excavation >4 ft below grade ❑ Hot Work (Sawcutting 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 lob clearance form. <br />Sign 1n Glow Out <br />Site Representative: Signature: Site Representative: Signature <br />CRA Field Leader: Signature: CRA Field Leader Issuer: Signature: <br />] 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? ❑ Are there any conditions requiring notification of station personnel? <br />mill fuel be delivered during work hours? ❑ Have all unsafe conditions, near losses and incidents been reported? <br />1TPXre 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 />M. <br />