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Work Order: 2268237 <br />5a API RtuowwwoFn PRArnct; IW <br />PERMIT To WOPA For PetrolownEmvitaience Sites <br />2., L&�. %A4 <br />Worker Signalums: i have ievoiwm and understand the condftrvs of ft <br />Worker <br />3. 4. <br />permit aqd t5 atlacl,rnents. I will report hazardow; conditions or acts <br />S B. <br />identified on trw% ]rosita LTiy supw . &y ur mer n;wesenk*w <br />7 1 3. <br />— <br />Person Enarge:44,T I Data- Gs 5" <br />work Order p Z.3� EquiPMOD! Time Inued:e1r,:io -miNpro <br />Nearest Mar ca Facility 8, Tore <br />REQUNWD PEMIFS ANMM PROCEMMS <br />0 Hot Aruk ❑ Excavation: Cheddist Lack-OulT829,id 0 Pre En_q Checklist JpConf <br />-W Space <br />E) One Call 0 ManaMment IXChen El ftri< wolffmficn <br />0 Other <br />CategUy of WOR <br />Descnbe: <br />0 Welding 0 Cut N 0 Dolling. 0 Grinalng M Sandblast C3 Other <br />Which of Of feA lowing %namal precautions are raq uffed? Check all QA a": <br />E3 Irisced Lxavatort El Adequate Barging 0 tocal PAKOM ON Q LO&4111 Tag -Out El Fuel Delivery 0 }Hydrocarbon sails <br />nearby Ll Veatt Stacks DCftryhazanis (list): <br />AlMOSDIteric last: 702: <br />MEL1 MZ) <br />Jot Control C-cnUd Name, <br />fire We" Mar" ft 1 <br />HAZARDOUS EMERGY LOCK -OUT TAG-OUrF IL07%—M 16" t2 <br />Has t -,A 0iWA Of equ pment of systerr, t*en prOpvisolated? <br />YES MA <br />Has he energy i22dlvon bow reviewed t;y md &*cW <br />list AllAffPr.W-Wa*,—s- <br />14.... <br />1 % <br />2... ��1,7A <br />T6 <br />Has'O to 0011, pe wed utility mark outs? YES NO :One Call Die Humber: <br />Has a line ja2jt2a serfice rrq*ied out utilities co -site? <br />�] WaMt 0 W@t ry <br />Woatnor GoWons: R.Wall Last 24 Wurs? trinditions 110 <br />m crosi-gnal ed axcavali o n Com petm I Pergon 7 fl -low deep is fe ex0avaWAO <br />Maqual njehMS to C48leM'Jr1A soil <br />0 Thumb on Tesl E3 Pocket <br />0 Plasticity <br />0 Dry °Sbertgih <br />dauffmalic-1: <br />Panallromeber <br />Visual <br />100b3emesamples demavaled L3Cbwwaxqwakn <br />0 011 adjacent <br />13 Observe soil as it <br />is <br />clwsWicalicn: <br />Mkonal walls <br />sudseema <br />atmayabad <br />Trench + Excnimiort Meaqiimmfirfla, Length: <br />VAIRIN: <br />Depth: <br />fif:- 41L also compkft pr*,epyjk!g!�� Poirmill) ..-- <br />Wnw is the So: Clas0calion? <br />E3 Slat. retch (yodoAl) E3 Class A (314! 11 <br />13 <br />El Class 5 (1:1) <br />0 0!n C (1 -511) <br />WMK4 SVarri(sl is used? <br />0 Sloping Shmirg <br />JE3 Tranch ShiedTrench Ekz <br />Ate Emo"sKept Cut da away ftum the excambon YES NO Emdonoo of spic" fiacture planes m soil or rock? YES <br />N <br />d_• Ingdig2 rig or mate.nal harwiling?. 0 El . — 5- <br />[3 <br />Have propef,4Wabons been made? 0 E3 Any SM of unusu* weak soils or m2llarots? C3 <br />[3 <br />.9 mere an exit c*entry point willhin 25 feet of eaM WNW. Q Q AfrLrow Eftwalic ft in bedmW. 13 <br />0 <br />Spoils, tools. Eq,;ipn)nnt >2 fael frorn exawation edge! ff (3 SW form exmvaaqrl (<U I'Murs)? 0 <br />El <br />Are zorrinadas -* ftalxin2 in plau? 0 11 Trench bW*sj-ceM6ad) a <br />El <br />'s fm—dh visibility clothing berg prop" wom? 0 0 Tansm cracks observed doM 94p& lop? <br />Utitit es or "UreS PrOWCM? Homule am Mped lo d" pmmm ' ? <br />E3 <br />Undergmund --ft eXpM-M? 0 0 Any!!!LW�F in exf;NoWn walls or bottom? <br />111mcing system installed aom,029 to 89iqn? 03 E3 is short secure? 11 <br />r <br />0 <br />a <br />Ev.c m= at shnnkaga cracks Pn e=vaWn, walls? Q El Trees, boulders, or other hamdds in area? 0 — <br />❑ <br />0 0 Vi1bm5cnftwTrWTrJequMMeat b&.. loodose? L2 <br />13 <br />Eviaence of cav�g or sloughin V= <br />.3_2�5als? <br />❑ <br />Are 5igns cut 84 design a� of sponse? (3 1� <br />_a <br />0 <br />IVOTE- &vavab= dam ffm 20 W MM AM MkC*e <br />otsewalio-6: <br />-LhRmby affea Mft above CMqM Raww0wo"Y&MML*ftMyftymd�m <br />Comp!j!" ftson Skinatm, <br />Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 <br />