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SectionTV;. ;,Line]8 kin <br /> 1. Line/Equipment positively identified? ❑ Yes ❑ NA <br /> 2. Line/Equipment properly drained/depressurized/purged/blanked? ❑ Yes ❑ NA <br /> 3. Line/Equipment cleaned of residual material? ❑ Yes ❑ NA <br /> 4. Bonding and grounding required? ❑ Yes ❑ NA <br /> 5. Non-sparking tools required? ❑ Yes ❑ NA <br /> 6. Atmospheric monitoring required? ❑ Yes ❑ NA <br /> 7. Containment/spill control required? ❑ Yes ❑ NA <br /> Section,V "'Atmospheric Monitoring (Complete for•Cohfined Space Entand Hot Work), <br /> Parameters Initial Periodic I Periodic ' Periodic Periodic Panodic Periodic Periodic <br /> Results Results Results ? Results Results Results Results Results <br /> ----....._.. _._ �...__ _�_._.. _..._ _ ...__.. �._. ..._..... _. . ...--_. _ _ . ..... <br /> Time Monitored <br /> ..__.�.... __. <br /> Testers Imtials/Signature <br /> Oxygen(19.5%-23.5%) <br /> Flammabil �< 10%LEL) <br /> Other <br /> ... <br /> _._.......... . ._. _. ... _____�......___......................... ___......__.. <br /> .. l. a. .�.. _. <br /> Other <br /> Sectioa,,Vl Persommel,,A obntabili Com fete for,all- oiinits <br /> Issuing Supervisor Signature: Time: <br /> H&S Lead Signature: Time: <br /> Entrant Signature: Time: <br /> Entrant Signature: Time: <br /> Entrant Signature: Time: <br /> Attendant Signature: Time: <br /> Attendant Signature: Time: <br /> Attendant Signature: Time: <br /> Employee Signature: Time: <br /> Employee Signature: Time: <br /> Employee Signature: Time: <br /> Employee Signature: Time: <br /> Section VII" <br /> Special lnstj�igt . m let&as necessary) <br /> Section VIII ContractorsCom Tete as recess, <br /> The following aspects of the permitted work activities have been discussed and coordinated with the contractor: <br /> 1. Roles and Responsibilities El Yes El No ❑ NA <br /> 2. Job Specific Hazards ❑ Yes ❑ No ❑ NA <br /> 3. PPE Requirements ❑ Yes ❑ No ❑ NA <br /> 4. Rescue Activities and Emergency Response ❑ Yes ❑ No ❑ NA <br /> Section IX Canceling,the%I'ernvt, tom late for all: ermits <br /> 1. Has the job,defined in the scope above been completed? ❑ Yes ❑ No ❑ NA <br /> 2. Have affected personnel been informed the job is complete? ❑ Yes ❑ No ❑ NA <br /> 3. Has equipment been returned to service? ❑ Yes ❑ No ❑ NA <br /> 4. Have safety devices been reinstalled? ❑ Yes ❑ No ❑ NA <br /> 5. Have housekeeping/environmental issues been addressed? ❑ Yes ❑ No ❑ NA <br /> Closeout Signature: Time: Date: <br />