COMPLIANCE INFO_2011-2013 - Laserfiche WebLink

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COMPACTOR INSTRUCTIONS PRIOR TO START OF WORK: t. Review form, check appropriate boxes, read and sips at the bolom of this form 2. Inform dealer, manager or representative of the ii In he repef rn i anti nnlpi onfaly r•nnrarne all nhfnin all era Station Address24 + iA6 Work order Number. �� Date: z ConlacpeSonln inarse NumberofW re: JSA Reference Nunber. e: E d Labs Ttave TraJWIOjsWrra: d u red f( ProbiemlWork Description: Return Call: yes l Damage Claim: yesl� SAFETY VEST M1 HARD HAT SHOES/900i ® HEARING PROTECTION ❑ RESPIRATOR PROTECTIVE CLOTHING GLOVES SAFETY GLASSESIGOGGLES ❑ FIRE RESISTCLOTHMIWELDING PPE ❑ OTHER Bil .. • . Task Step Hazards Not Covered by JSA How to reduce or eliminate risk — include extra PPE to be worn ------------- - -- - -- ---- --- --- ---- -- --- -----------•------------•----- ----------------------�------------------- --------------------------------------------------------------------------------•--------------------------------------------- ------------------------------------------------------------------------•----------•--------------------------------•------- ------------------------------ ---------------------------------------------------------------- ------------------------------------------------------------------- Work documentation requirements Lower ask—This form may be used as JSA Medium Risktli;i r Risk — JSA Required Higher Risk - JSA Required and other customer requirements may apply Examples of hirlher/medium Risk Tasks ❑ Works at heights ❑ Work in confined spaces (ex. Tank, interceptor, or manhole entry) ❑ Trenching or excavating ❑ Hot Work ❑ Hoisting/Rigging/Heavy Lifting ❑ LPG system degassing, installation or maintenance Contractor representative name Signature• • ° - • - • • • • Contractor si nature ng silos: to be sgned by the site representarwe lContmdo eENERAL SAFETY CHECKS BY CONTRACTOR erating sites: to be signed by Contractor • Has the work area been left and safe? representative only • Is rise site operator aware of status of work including any remaining isolation? r responsibility to inform site of Site representative name Signature •Are dtalrgesio equipment Site rept a name Signature • Hazards of the job, ContraM has di Job pearar am documented and communicated? • Effects on the site or operation, • Ag incidents. new misses• ansate • Any affect to gasoline deliveries, sttuatons reported? G. ° to rep— Fess ve comm • Energy isolation needed, •Areas to be barricaded for worker/pubiicsal - ---------- -------------------- -- - - -- - --- - - --- --- --- - - ---------------------•--------•-- -------------------------------•--------•----------- ---- PARTS — Ordered, replaced and/or disposed of {Include model and serial numbers as appropriat Tha MnIMf tnf fi fir. n� ilc 7t ii nr aim nMlw { tl -J •,._-___._-.___.-_�.___...__.__......_.a..,.--- .............•.,...q,wr•�owmc. Ivi qp w�v,calanw rvl u,a gala me uuayauvns reran tg mere arse/ appPCdDle lO Ute V/errC This form covers important reminders and is not intended to relieve the contractor from safety 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 tailing to comply with the requirements in the applicable items of this form or other applicable safety requirements WHITE SSSJASLE OFFICE COPY YELLOW: SEND WITH INVOICE PINK: LEAVE ON SITE