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This form shall only be completed by an Approved,Competent,Authorized and Qualified person. <br /> This form is required to be g2T21etecl and posted on All sites where Chevron work Is being performed. <br /> Chevron ® NA <br /> General Work Permit I GW,.:L*1i14? 2.UK <br /> Retail/M&CM& Siatiaidlt?aetTrae ____-t <br /> This permit is to be used for Set!-PermittIng at Norlb America Retail This Permit to be Displayed at Job Ska <br /> Store k4gn ergnature:I acknowledge that I have been made aware of the work activities covered by this <br /> permit and Wit work wilts the work crew foremarVsuperinterident to coordinate safe operations. <br /> (Signature required on active sites before tris permitbecomes eftcthle) 8140650 1 dF41-im—Sigraiwe!Date' <br /> WofkOrdw# Lt01A:A-f't07r6 Equipment ID - qltion 0 <br /> Who requested and auftited the wA: :[A:t% <br /> Description ofllitork to be authorized by this Pern-ft A-V V A­ <br /> I List Types of Toots and Equipment_Required: <br /> 5- <br /> a-dica'� di otodl a <br /> L.-acfi!7jFn�re 'T Nqg2e_" ��� <br /> Ernerqenc:V!Rescue Phone; I <br /> GENERAL PERMIT REQUIREMENTS <br /> FE Pe-mit Issue,to check itenis, jircd bolaw and once verilladas completed,the res 0 to initial this form <br /> Pre-job solely briefing,including simultaneous <br /> Rr <br /> A Assessment; <br /> I operations-SIMOPS <br /> I At employees understand their Stop%Vork Authority and mx Ail employees am properly trained to the appropriate <br /> ,a ality. tt <br /> level for the-imik SII ba_Rer'pm, g <br /> Review of wrrk pm. wduros 17f <br /> ASJ JLAIJSA-required for all high risk work <br /> A 2�may radio rcquired on site AvpaNe Area is raquired to be barricaded <br /> Approved scedding is required to perforin the job task Fah protection is requirec <br /> JK. <br /> d <br /> Eq-tipirient required to be depressurized 0 equipment require to be drainel. <br /> 10 Standby Person required during performance-of viork Fl <br /> HES I M Salety Pian as reqwtfed <br /> SpedPPE andior c1o!hingrequired----List CASic. S11%r_S4_T <br /> Respiratory protection required Ust type required: <br /> A�".ergy soyroesIn equippm.ent,isolated,locked and togged using proper Lod:-out&Tag Out prjoedures <br /> iMSRE'provided 9 Ha7was Feviened 4ist*-- <br /> 0 in <br /> Additional; stractions,c*nditions andlor rcq*erniantss listed ladmu Have beer;met. <br /> ADEiii6iiAL REii) I P1oRMIT FORMS ANDIOR PROCEDURES TO ACCOMPANY THIS GENERAL WORK PERMIT <br /> ADE)ITJ0wAL PAGES PERMIT FORMS TO BE ATTACHED TO THIS GENERAL WORK PERMIT <br /> Hot work l Equipment ismazion Checklist(LOTO) Q Excavation and Trepciting I n Hoisting/Rigging wCl—Pre Entry Checiftt <br /> Confired Space 1_Cl Work at 11.e1" Energized Electrical Wok 0 Gas test results Q OWer_ <br /> T_; <br /> PERMIT TO WORK For PatroleurnfConvenience Sites 1 <br /> kYorker Sionaturas:i have revielyed and understand We conditions of this <br /> S'I I <br /> C <br /> permit ane its attachments. I will report hazardous conditions or acts 4. <br /> identified on this jobsite to my supervrisor or customer representative.My <br /> 1! <br /> svjnature inclica S shat I ftay understand and%VM fully compy 10%, all 5. 0 AddrtonA worker sic ginatures are <br /> condilions a 'cements of*f-CUlf Per mlled Form. 4whided on the back of this plemaot <br /> I ensure this permit has been ffibied out completely and inamiunctiton witft ad appGcabieOSHA <br /> !�L4Aq i Wark9afn BC requirements to provide a see workplace for a)i workers and myself. hvifltaF <br /> FeMl::5 <br /> 1167}: reTxeTi action to eliminate ha7ardaus condition.or am.identified or,fnis job site. <br /> )0q,y <br /> Po'm- <br /> i <br /> t <br /> — <br /> ' Date 9 Tma VV <br /> o <br /> k Completed <br /> 16hrsmax7--t <br /> IeA P- -y (kI s)PNinit Isswei <br /> en a a i-i comHy Names <br /> Renewal <br /> ThIs perinitmoo_ba renewed u to 5 consecutive day.but concriftmust b®revattdated each lav- __ <br /> — <br /> Mks gaa+ttire be!ow indicafi�sani its and cc Worm of this GVVP and referenced forms amain in efflact ane work con be Perfornied So <br /> Nates 1;Su-r_StgV.1s(I vW.Wl to Ile ri!=dad on"s fw.m cr an ace aiIacned v*V.anenW Gas-ifial Recons 3WaL <br /> 2)1'*rww.vai Cd a%md Wwk Pemm wdvirra Conreared E is <br /> Valid To Permit issuer-signature Ut <br /> 0_-Its -iiZ <br /> Valid From In Uri <br /> star time fen <br /> e I Isamedayonly) (renewal extension} <br />