Permit Review By Date SAFE Work Permit Information
Permit Review By: Date: SAFE Work Permit Information to be completed by Permit Requestor/Holder Company: Contractor Name Meraux Refinery Area/Unit Permit Holder: Equipment # # Persons: q Cold Work q Low Energy Permit Number: Tools/Equipment to be used: q Hand tools q Lift trucks q. Double Insulated Work Order #: Scope of Proposed Task: Electric Other: Please initial that the Scope of work is clear and understood. Permit Holder: Permit issuer: Information to be completed by Permit Issuer. Previous Product in Equipment: MSDS Yes Checked N/A Additional PPE Required? Equipment Pre-Work LOTO Procedures Followed • Blinded/Disconnected • Equipment Opened/Depressurized • Valves. Closed/Tagged/Chained/Locked Req’d Done Equipment Pre-Work Y -- N Lock Box Number: Y -- N Decontamination • De-energized Electrical Systems • Electrically Locked-out/Tagged Specific Hazards: Out • Field Test / Attempt to Energizestart Req’d Done Y -- N • Water Washed Y -- N • N 2 Purged Y -- N • Steamed Y -- N • Y -- N Blinds Verified & Blind-List initialed Y -- N Area Preparation Bottle Watch Additional Standby Low energy work Preparation • 120 V Electrical equip GFCI • Prepared for Vehicle Entry Req’d Done Y -- N Y -- N Other -- N Instructions: • Sumps-drains covered Additional Controls and/or. YSpecial PPE Y -- N Req’d • Electrical Connections Standard (SSPRadioactive Sources Secure Y -- N Taped Y -- N 0011) • Vehicle Wheels Full Face Shield Y -- N Chocked Goggles Y -- N Hearing Protection Y -- N Fall Protection Y -- N Leather Gloves Y -- N Rubber Gloves Y -- N Non Permeable Suit Y -- N Respirator ½ face Y -- N Respirator Full Face Y -- N Filter Type: Supplied Air Y -- N Personal H 2 S Y -- N monitor HF Alky -- LEVEL “A”: Totally encapsulated suit – positive pressure HF Alky -- LEVEL “B”: One piece coverall, gloves w/sealed cuffs, HF boots, positive flow hood w/ air line. Alky -- LEVEL • Signing this Work Permit signifies the job site has been inspected by the Permit Issuer and Permit HF Requester/Holder, “C” : One Coverall, HF the area is prepared, and each individual has agreed to comply with the conditions of this permit. Boots, Piece Gloves w/sealed face shield • The Permit is valid through the end of the current work shift (start and end times below) and may. Cuffs/ be extended into the next shift if necessary. Test 1 Time Start Test 2 Date All Signatures are Required PRIOR to INITIAL work. Time Oxygen Authorized Continue Time Expires Print Name Signature Date Permit Holder LEL Permit Issuer H 2 S Chief Operator (if required) CO Benzene Other Serial # Calibrated? All Signatures are Required PRIOR to EXTENDING Permit into the following shift. Authorized Continue Print Name Time Start Time Expires Signature Date Permit Holder Permit Issuer Initial -- Meraux Qualified Person Permit End Permit Holder Unit Chief Operator (if required) Work Safe/Clea Expose HF PPE Comple n Jobd Cleaned te Site? HF Acid ? Y N Y N Print Name Signature Date Time
Please designate if this is “Cold Work” or if Low Energy which includes only Vehicular Entry into a unit or low voltage only work. Please see hot work permit instructions Check if Meraux personnel doing Check and indicate Contractor Name for work contractor work The Permit Holder completes this section of the permit prior to Person responsible for directly supervising the meeting wit permit issuer. work. Indicate work order How numbers many will be involved performi List tools & ng work equipment to The Permit Holder should describe the scope of work to be completed in be used. this area. Permit Issuer is an operator for the area involved << Indicate if the MSDS was checked for the previous product in the vessel and any additional PPE required. Indicate product last in vessel so proper PPE can be assessed. . n The permit issuer and Permit Holder also ensure area preparation is required and Done for Bottle Watch or Low Energy Work. ev i sio The Permit Issuer and Permit Holder work through this section to ensure that: 1 – all Equipment Pre-Work area are checked to indicate what is REQUIRED (Req’d) 2 – to ensure that all REQUIRED Pre-Work is actually DONE The Permit Issuer and Permit Holder also inspect the area for Job Hazards. In this area if a Job Hazard exists the box should be checked. Standard Controls or other appropriate measures should be taken to ensure the area is safe for work. s. R Also – potential Environmental impacts are noted below: Clarify additional controls or special instructions for the work. . Ne ed Identify any additional or specific Hazards of explanations of certain above information. A Meraux employee (or designated contractor during turnaround events) who is qualified to do air testing must test the work area prior to any Vehicle entry or other low energy work being performed for this permit. These readings are noted here. A signature is required If HF Exposure– indicate and Based on the work and hazards – specific required PPE should be Identified for the permitted work. If HF Alky involved indicate PPE Level These names, signatures and date must be complete and the Start and End time for the permit set (above) prior to work start. If, at the end of the shift, it is necessary to extend the permit, the on-coming Permit Holder and Issuer must review the area to ensure conditions have not changed and re sign the permit with start and end times. When the work is complete the Permit Holder and the Unit Operator should review the work and indicate whether it is complete and the site is in Safe condition – then print and sign their name and date the form.
Permit Number: JSA Task Specific Job: Purpose Date: Job Hazards Y Standard Controls Job Hazards Y Static Electricity Grounding, Slips, Trips & Falls Chemical /Fuel Exposure Vehicle Entry in the unit? Housekeeping, & PPE MSDS Review, PPE Overhead Hazards Procedures, Barriers, & Permit Sharp Edges Electricity Isolation, LOTO, GFCI Activities of Others Flammable Vapors / liquid Gas Testing & Isolation Access & Egress Housekeeping, Walkways, Stairs Trapped Pressure Venting, Draining, & PPE Fumes & Dust Hot Surfaces Special PPE Required: Toxic Vapors / Liquids Excavation Comments: Weather Extremes Spillage to Ground Spillage to Water Respirator / Eye Protection Insulation / Barriers / PPE Vehicle Traffic Gas Testing & Isolation Underground Hazards Excavation Checklist Hot Liquid Schedule, breaks. Working at Height Secondary Containment / Booms Working Over Water Mechanical Lifting SEQUENCE OF BASIC JOB STEPS PPE Standard Controls Manual Handling / Lifting Moving Parts Assessment & lifting equipment Covers, Isolation, & Maintenance Labelling, Isolation, & Barriers Covers, PPE, & Equipment Inspections Communications, Barriers, Permit Hi-Vis Clothing, Speed Limit, & Signs CAT Testing, Labelling, & Barriers Procedures & PPE Scaffolding & Fall Protection / Harness Life Jacket, & Safety Boat, Barriers / Lift Procedures Req’d Standard (SSP 0011) Full Face Shield Y -- N Goggles Y -- N Hearing Protection Y -- N Fall Protection Y -- N Leather Gloves Y -- N Rubber Gloves Y -- N Non Permeable Suit Y -- N Respirator ½ face Y -- N Respirator Full Face Y -- N Filter Type: Supplied Air Y -- N Personal H 2 S Y -- N monitor HF Alky -- LEVEL RECOMMENDED-SAFE-JOB“A”: POTENTIAL ACCIDENTS OR HAZARDS Totally encapsulated suit – PROCEDURES. positive pressure PREVENTIVE OR HF CORRECTIVE ACTIONS Alky -- LEVEL “B”: One piece coverall, gloves w/sealed cuffs, HF boots, positive flow hood w/ air line. 1 HF Alky -- LEVEL “C”: 2 One Piece Coverall, HF Boots, Gloves w/sealed Cuffs/ face shield 3 4 5 6 7 8 9 10 11 12 13 14 Comments: Supervisor: Analysis by: Department: Reviewed by: Location: Approved by:
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