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r Compliance without Compromise P.O. Box 4208 Sonora CA 95370 Ca: 623541 A-Haz Phone: 209-532-7320 Fax: 209-533-2650 mail@alltechpetro.com www.alitechpetro.com CONTRACTOR INSTRUCTIONS PRIOR TO START OF WORK: 1. Review form, check appropriate boxes, read and sign at the bottom of this form 2. Inform dealer, manager or representative of the job to be performed and potential safety concerns and obtain signature Station# 2093 Station Address: 3425 Tracy Blvd. Tracy, Ca Work Order Number: 9858888/9862777 Date: Nov 28, 2012 Contractor Company Name: Alitech Petro Contact Person In Charge (print name): Isaac Anderson Number of Workers: 2 JSA Reference Number: (if required) Start Time: 9:30 am Problem/Work Description: Perform Annual Monitor Cert/ Healy Quarterly Inspection Departure Time: End Time: 12:30 pm Return Call: 0 yes IMIno Travel Time: Damage Claim: yes no Travel Distance: Safety Vest iL Hard Hat 'l Shoe/Boots U Hearing Protection Uw, Resperator Protective Clothing JVJ Gloves IA Safety Glasses/Goggles Fire Resistant Clothing Other Task Step Hazards Not Covered by JSA h{oW to reduce or eliminate risk -include extra PPE to be worn ....... ......... ......... .................... ........... ................ ........... .......... ........ ......... .. .. .................................. 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 higher/medium Risk Tasks Works at heights „ Work in confined spaces (ex. Tank, interceptor, or manhole entry) Trenching or excavating 0 Hot Work Hoisting/Rigging/Heavy Lifting Q LPG system degassing, installation or maintenance The contractor through its authorized representative shat sign, issue and be solely responsible for at Job clearance Forms and the obligations arising there under applicable to Itre work This form covers important rombxfer8 Wlsoot intended to relieve the contractor from set* 'iheaauk kr compliance with applicable laws and regulation s 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 requiremreMs in the applicable items of INS i"or ether applicable safety requirements 11 Contractor representative name Signature• r ' t • Has' I Operating sites: to be signed by the site Isaac Anderson GENERAL SAFELY CHECKS 1Y CONI representative Non-operating sites: to Has the work area been left be signed by Contractor representative • Is the site operator aware only remaining isolation? Contractor responsibility to inform site of: I Site representative name I Signature I • Are changes to equipment • Hazards of the job, documented and communicated? r • Effects on the site or operation,- I q b -- I • Ag Incidents, (rear misses, unsah • Any affect to gasoline deliveries, ar Site representative comm, en • Energy isolation needed, • Areas to be barricaded for worker/public safety PARTS — Ordered. replaced and/or disposed of (include model and serial numbers a p The contractor through its authorized representative shat sign, issue and be solely responsible for at Job clearance Forms and the obligations arising there under applicable to Itre work This form covers important rombxfer8 Wlsoot intended to relieve the contractor from set* 'iheaauk kr compliance with applicable laws and regulation s 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 requiremreMs in the applicable items of INS i"or ether applicable safety requirements 11