COMPLIANCE INFO_2009-2011 - Laserfiche WebLink

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CONTRACTOR INSTRUCTIONS PRIOR TO START OF WORK: 1.Review form,check appr9priate boxes,read and sign bottom of form 2.Inform dealer,manager or representative of the job to be performed and potential safety concerns and obtain signature Station# 1§C Station Address 5- �} a;t- Work Order Number. Cry ��? J 7 Date: -D1 / Contractor Company Name:Wayne Perry, Contact perso In Charge(pant name): 7umbep$Workers: JSA Reference Number Start Time: End Time: Labor, Travel Time: Travel Distance: Inc-SoCai <tt 1 (if required) ' Problem/Work Description: co, La LAi b , k? - Return Call: yes/no Damage Claim: yes/no SAFETY VESTHARD HAT HOES/BOOTS ❑ S � `` HEARING PROTECTION ❑RESPIRATOR La,P11OTECTIVE CLOTHING ZIGLOVES -SAFETY GLASSES/GOGGLES ❑FIRE RESIST CLOTHING/WELDING PPE ❑OTHER Task Step Hazards Not Covered b JSA How to reduce or eliminate risk-include extra PPE to be worn --------------- -------------------------------------------------------------------------------- ---------------------------------------------------------------- --------------- -- ------------------------------------------ ---------------------------------------------------------------- y 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 Examples of higher/medium Risk Tasks Permits-to-work are mandatory for all of these activities(see API RP#1646 Appendix 133 for permit forml ❑Work area Barricading(permit-to-work not required) ❑Trenching or excavating ❑Hoisting/Rigging/Heavy Lifting El Hot Work ❑Works at heights (permit-to-work not required) ❑Ener ( Tag,Try) ❑Work in confined spaces(ex.Tank,interceptor,or manhole entry) q' 9Y n I (Lock, ,�,r� .�;. m� � 'nig,ri�dy�''iH � i str iia a�•xa�e ?a q. nxk^}a''; '4. .1. � ��siL.. +� :�5 .4,,a�'4"'�;� �,b^'. ' �w •..�r.:<E.,—:,. +s<+<,=w: ! c� ". I i, �,^4,�.�a+,, ,.4s�ti�.irF�,F�M�m-r.,^.� Contractor worker name Signature LCILIKS11K.1 n-161-n-c- s- s s •- Contractor signature Operating sites:to be signed by the site 5 GENERAL SAFETY CHECKS BY CONTRACTOR representative. d •Has the work area been left tidy and safe? Non-operating sites:to be r^ L, l C.-•• s .Is the site operator aware of work status and any remaining isolation? signed by Contractor representative only Site representative name Signature .Are changes to equipment - Contractor has discussed,Job Clearanceorin With me documented and ;ontractor responsibility to inform site of: Site representative name Signature • Hazards of the job, communicated? • Effects on the site or operation, ` •All incidents,near misses,? I u • Any affect to gasoline deliveries, unsafe situations reported • Energy isolation needed, Site representative comments: • Areas to be barricaded for worker/public safety. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- — - PARTS-Ordered,replaced and/or disposed of(include model and serial numbers as appropriate) 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 the work This form covers important reminders and is not intended to relieve the contractor from safely performing the work in compliance with applicable laws and regulations 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 form or other applicable safety requirements