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Job Clearance Form CONTRACTOR INSTRUCTIONS PRIOR TO START OF WORK: 1,Review form,check appropriate boxes,read and sign at the bottom of this form 2.Inform dealer,manager or representative of the job to be performed and potential safety concerns and obtain signature Stathi In talion Address:5'�4 ! INo rder Number:,- ��. '*A f-- Date ac r Co a _ - Contact person In Charge(print name): Number of Workers: JSA Reference Number: Start Time: End Time: Labor. any Name: require Travel Time: Travepislance: 1 CQrI 11 I r if re uired ?� Problem/Work Description; J n�RancnReturn Call: yes 169..: .1 Damage Claim: yes no r `F.SAFETY VEST ❑HARD HAT ,,Q SHOES/BOOTS ❑HEARING PROTECTION ❑RESPIRATOR JJZ PROTECTIVE CLOTHING GLOVES T SAFETY GLASSES/GOGGLES ❑FIRE RESIST CLOTHINGContractor to complete section below it circumstances on site or /WELDING PPE ❑OTHER specific additional hazards not described in the JSA .. Task Step of Not Covered b JSA How to reduce or eliminate risk-include extra PPE to-fb-e worn ��eL�J ___c�. �.lp___.�Jr t/_r_�_____________________ / -------------- -- - - - - - -------------------------------------------------------------- _ ---------------- - er �' t-- ------ 61 �rtC�.JIft'/ _ ------------------------- I'' Il -� r ---'-�� `=- j �. 5f- Work documentation requirements Lower Risk-This form may be used as JSA Medium Rlsk/Higher Risk-JSA Required Higher Risk-JSA Required and other customer requirements may apply Examples of higher/medium Risk Tasks ❑Works at heights '-�Mork in confined spaces(ex.Tank,interceptor,or manhole entry) ❑Trenching or excavating ❑ Hot Work ❑Hoisting/Rigging/Heavy Lifting ❑LPG system degassing,installation or maintenance • • M Contractor representative rr,�me Signature ff- • •• • ' • • • • Contractor signature r.1NEL SAFETY CHECKS BY CONTRACTOR , Operating sites to be signed by the site representative _- _XA � ;- ework area been left tidy and safe? Non-operating sites:to be signed by Contractor _ site operator aware of status of work includirg any remaining Isolation? representative only •� _ Are changes to equipment Site representative name Signature Contractor responsibility to inform site of: Site representative name Signature documented and communicated? _ 1 • Hazards of the job, •All incidents,near misses,unsafe • Effects on the site or operation, situations reported? C r • Any affect to gasoline deliveries, Rite reoresentative comments ff" ------------------------------------------------------ ----------------------- • Energy isolation needed, • Areas to be barricaded for worker/public safety. ------ ----- - ---------- ---------------— --- ---- ------------------ PARTS-Ordered,replaced andlor disposed of(include model and serial numbers as appropriate The contractor through its authorized representative shall sign,issue and be solely responsible for all Job Clearance Forms and the obligations arising there under applicable to the work This form covers important reminders and is not intended to relieve the contractor from safely 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 failing to comply with the requirements in the applicable items of this form or other applicable safety requirements ----- -•-• --........�.............r nrnrrr.r CAVP Ml CITF