Permit Number Work Permit Meraux Refinery Contractor Name

Permit Number: Work Permit Meraux Refinery Contractor Name Information to be completed by Permit Holder Company: Meraux Refinery Area/Unit Permit Holder: Equipment # Date: Work Order # (s) # Persons: Scope of Proposed Task: Information to be completed by Permit Issuer. Work Description: MSDS Yes Checked No Previous Product in Vessel: Y Comment: Y Adverse Weather Chemical Exposure Standard Controls Housekeeping, Walkways, Stairs Communications, Barriers, Permit Stop Work & Take Refuge MSDS Review, PPE Vehicle Entry Procedures, Barriers, & Permit Sharp Edges Electricity Exposure to Fuels Fatigue Isolation, LOTO PPE Rest Periods, Refreshments Slips, Trips & Falls Static Electricity Trapped Pressure Insulation, Hearing Protection, & PPE Labelling, Isolation, & Barriers Covers, PPE, & Equipment Inspections Housekeeping, & PPE Grounding, Venting, Draining, & PPE Fire & Explosion Gas Testing & Isolation Vehicle Traffic Hi-Vis Clothing, Speed Limit, & Signs Fumes & Dust Filter Mask, Eye Protection Underground Cables CAT Testing, Labelling, & Barriers Soil/Water Contamination Isolation Hot Liquid Procedures & PPE Secondary Containment Procedures Working at Height Hand Rails, Harness, & Life-Line Job Hazards Access & Egress Activities of Others Hot Surfaces Nature (insects, snakes…) Job Hazards Additional Controls Required: Procedures & PPE Req’d Standard (SSP 0011) Manual Handling Assessment , & Equipment Moving Parts Covers, Isolation, & Maintenance Noise Overhead Cables Working Over Water PPE Standard Controls Y Full Face Shield Goggles Hearing Protection Fall Protection Chemical Gloves Chemical Suit Respirator ½ face Respirator Full Face Air Supplied Hood/Line SCBA Personal H 2 S monitor Special Life Jacket, & Safety Boat, Instructions: Other. . Y Awareness, Remove, PPE Equipment Pre-Work LOTO Procedures Followed Req’d Done q Blinded/Disconnected q Equipment Opened/Depressurized q Valves. Closed/Tagged/Chained/Locked q Electrical Systems q Field Test / Attempt to Energize- Equipment Pre-Work Lock Box Number: Blinds Verified & Blind-List initialed Decontamination Req’d Done Area Preparation Req’d Done Additional Stand-by Personnel q Contact: q Water Washed Lighting q N 2 Purged q 120 V w/ GFCI q Steamed start Blinds Verified & Blind-List Air testing is required forinitialed low energy – non- Hot Work permitted activity. If test are taken, Chief Operator must be notified. No Date Time %LEL Oxygen H 2 S CO Other Serial No Meraux Qualified Person: 1 2 Signing this Work Permit signifies the job site has been inspected by the Permit Issuer and Permit Holder, the area is prepared, and each individual has agreed to comply with the conditions of this confined space permit. The Permit is valid for a period of up to 12 hours or may be extended (below) for up to 24 hours. All Signatures are Required PRIOR to EXTENDING permit up to 12 hours. All Signatures are Required PRIOR to INITIAL work. Authorized Entry Print Name Signature Date Authorized Entry Permit Holder Permit Issuer Chief Operator (if required) Permit End Work Completed Work Site in Safe Condition Permit Holder Yes No Yes No Unit Operator Yes No Print Name Signature Date