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This fbrm shelf only be completed by Mut Approved,G and Ottallflad penmm. <br /> This form Is fred to be wid a1 AN An where Chevron work is <br /> 7hb P y0d at JobSn. <br /> S� t tltat E have been d Ehe work by gtis � . <br /> pm*and wS work MM ft work cm petkt to comande safe opullorm <br /> Q1 mcbm sfla5 ®o at 6 un D* <br /> WWkOr4W# I V. Caish4m or Maklanance work ore <br /> Who requestsd and adatzed the wok: <br /> d Wok to be aultmized by ft Peng e�� L,o s j E;-3 rd ' & l e,-sZ-/,V <br /> LWTypeSofT0*andEqj0nWRequW. I AAIV <br /> Neared Medical€ Phone/ C• S�70 Name ofF a /`sl t7rL <br /> Wt 40 <br /> ®PamRIs=toCImdft=m*iWbeIcmrandoncevaffiWSS tlta to vabla party to fnU ads form <br /> ® J(W I Pre** - bria <br /> ® PA isrovIses understand their Stop Wok AuMoft and We® Al mploym are properly trsingd to tfte apgopruft <br /> level for ft work It <br /> m w11 be <br /> �, ❑ JWJSA-mWhd for d No risk wok <br /> ❑ ear Approved 2-my radio required on site Area a Omd to be Wfficadsd <br /> ❑ ,�, Apmed scdfdit is r%*W fD ft tab fat ❑ Fal MWm is <br /> to be t moed to be drained <br /> ❑ «airMlwbyPmm mow" of—k ❑ HES I Ske Plan Wdred <br /> PPEandfa doftq taquied List AF'6 t n* <br /> ® ft~MvWbm mWed Ust typo <br /> ❑ M WAV sauraSh> and tagged Laing proper Lod-M&Tag out Wceftes <br /> ❑ MSDS"ViW&Hazards reviewed List <br /> ❑ andfar have mean met. <br /> ' crioducbm <br /> ADDITIONAL REQUIRED PERMIT FORMS ANDVOR PROCEDURES TO ACCOMPANY THIS GENERAL WORK PERMIT <br /> —ADOMONAL PAGES PERMIT FORM TO BE ATTACHED TO THIS GENERAL WORK PERMIT— <br /> ❑Hat Work I ❑Epowd Isoldon OmMst(LaTo} ❑ and T ®H*l ❑Pre <br /> ❑Cadried Space 10 Wok at ❑Energized BKWW Wok ❑Gas tast results ❑Ognar <br /> PERMIT TO WORK For leam/Contntnlem Sites T• 2• <br /> Wakes 5lonakaes I have and undarstand the OWAM of fids <br /> pmA and its abdurwft I wig repot hazaadom cmftm or acts 3. 4. <br /> idenWW on this jobsite to my supervisor or ambner repesenAmm My <br /> *nabft Mates OW I k*undamtend and wS Gaily wet al 5. DAdOmalworlwolnuhumsm <br /> corddons and of this Self Peardled Form kdww at tip bade of dds pem it <br /> I wmn ft pennit has been Ned out and In vA al appkabla OSHA <br /> I WwkSde BC raWfurnards to pvMe a sato wm#lm for all workers and myself. I wR take <br /> to r Pa tauai:t ) actkn to Offinble hmmVWA conallons or Seta dad9nad at this job sma. <br /> Pemlit vdd From: f I Tkrc. 7itv- Tk m Want CmodBd <br /> PWVA To: S Tkne-. Iff;110 6 tars max trot-l •!3 141%yo <br /> _.. <br /> esteEdension Tkne Fran: To: <br /> PeRnit <br /> ?4!NnWn bdow kdcmm al find cmdmo of fid GWP and Isbanced famS mmah in dW and me work can be <br /> noes n)G.rTeanxtQl tBtenQoneik6emormw Ga.Tatttaaasr <br /> Tiesr dsGaretwbotFWm* k <br /> Date Vakd From Valid To issuer Extend tai: Perth IstAm-*nabse <br /> (start drne ow em sane sm <br /> Revised May,2010 Latest version can be downloaded at feWorkPmctices/ofo.asox <br />