Safe Work Permit

PERMIT #
Type of Work Date Issued Time Issued Cold Work Hot Work Confined Space Entry Issued To: Valid From: To: Permit Extended To: Approved By: Special Jobs

__________ am/pm ___________ am/pm Location(s) of Work: Description of Work:

__________________ am/pm

GENERAL CONDITIONS OF WORK 1. Has the work area and surrounding work site been examined to ensure they are free from hazards and that they will not create a hazard for this work; has this permit been discussed with 2. Have wind and atmospheric conditions been considered to ensure workers safety? 3. Are vehicles allowed into the work area? 4. Are necessary barriers and warning signs in place? 5. If applicable, identify material/product normally found in this equipment: Flammable Toxic Corrosive Hot Other: 6. Are workers familiar with the applicable MSDS? 7. Has the necessary equipment been isolated by: Blinding Dbl. Block & Bleed Closed & Locked Valve Plugged Disconnected 8. Has the necessary equipment been decontaminated by: Air Nitrogen Steam Water wash Forced Ventilation Other : 9. Have energy sources been locked and tagged? Electric Steam Gas Pneumatic Hydraulic Cathodic Protection Heat Tracing 10. Have overhead & underground hazards been clearly identified? 11. Have all flammable material sources been identified, removed & covered? (sewers, open containers, spills, etc.) 12. Is any special fire, emergency, rescue equipment required? Extinguishers First Aid Kit Portable Radio Air Movers Low Voltage Equipment Other : 13. Is any special personal protective equipment required? Chemical Clothing Goggles/Face Shield Rubber Gloves / Boots Breathing Apparatus Safety Belt/Harness Other: 14. Are precautions necessary for radiography work? 15. Has the necessary equipment been bonded/grounded? 16. Is a watch person required for: Confined Space Entry Hot Work Vehicle/Crane Manoeuvring Other: 17. Have the necessary gas tests been performed? Periodic Continuous Results: flammable Oxygen Comments _______________% LEL ________________ % VOL H2S _______________ PPM

N/A

Other ________________

Agreement: I have reviewed both the job and the permit - I understand the nature and extent of the work and agree to abide by all the conditions and precautions as stated above to complete the work safely. Permit Issuer: ____________________________ PRINT _____________________________ SIGNATURE Additional Approval when Required Lead Operator: _____________________________ PRINT _____________________________ SIGNATURE Time: ________________ am/pm Complete Incomplete Permit Receiver: ______________________________ PRINT ______________________________ SIGNATURE # of workers on job _____________________________ # of vehicles on job _____________________________ Receivers Signature: ___________________________

PLEASE RETURN & SIGN OFF PERMIT WHEN JOB/SHIFT IS COMPLETE. Job Status:

Page 316 of 421 [Company Name] Accident Prevention & Safety Manual

Hazard Assessment Form

Date: ____________________ Job#: ___________________ Customer: ______________________________________________ Location: _______________________________________________

Completed by: ________________________________________________________________

Reviewed
Customer Specifics program/rules/procedures pre-job review who will supply what contacts/communications multiple crews/contractors Emergency Response first aid station fire extinguishers eyewash/shower evacuation point emergency contacts/procedures Work Site lease layout (safest) traffic/road crossing heavy equipment overhead power lines underground utilities/lines Wildlife creek/water crossing Housekeeping weather-related hazards high pressures high temperatures steep slopes soil stability Chemical Hazards MSDS specialized PPE H2S lease any other chemicals (list) _____________________ _____________________ Work-Related Hazards confined space pressure testing/pigging ROW prep/brush clearing heavy equipment hoisting/stringing hot work blinding/isolations excavations/trenching pipe handling
Reviewed with: (attendees at pre-job safety meeting) Attendees: ________________________ ________________________ ________________________ ________________________

What are other hazards:

________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________

Precautions:

______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________

Page 317 of 421 [Company Name] Accident Prevention & Safety Manual

Worksite Safety Inspection Form

Location: Items to Inspect: Buildings & Structures Windows, Floors, Doors, Stairs Elevators, Escalators, Manlifts Aisles, Work Surfaces Lighting Electrical Wiring, Cords Exits, Alarms, Emergency Lighting, Drills Fire Protection Equipment Heating & Cooling Sanitation Storage Facilities, Areas Bulletin Board Item# Location

Inspected by: Atmospheric Conditions, Ventilation Toxic Material Storage, Labels Flammable Liquid, Gas, Labels, Storage Containers Pressure Vessel, Inspection Materials Handling Equipment Containers Production Equipment, Guarding Controls Hand & Power Tools Ladders, Scaffolds Vehicles Hazards Observed

First Aid Kit, Contents of Kit, Training Personal Protective Equipment Operator Authorization Warning Signs, Labels Safe Work Practices Proper Lifting Housekeeping Maintenance Safety Training Smoking Locker & Lunch Room Job Procedures Priority Date/Time Action

*Priority Index

1. Imminent Danger

2. Serious

3. Minor

4. Acceptable Review (Date): __________________

Copies to: ______________________________________

Comments: ____________________________________________________________________________ ____________________________________________________________________________ Managers Signature: ____________________________________________

Page 318 of 421 [Company Name] Accident Prevention & Safety Manual

Worksite Safety Inspection Form

Worksite Inspection Report Inspection Location: ___________________________________ ___________________________________ ___________________________________ Department/Areas Covered: ____________________________ ____________________________ Repeat Item Yes/No Date of Inspection: ___________

Time of Inspection: ____________ For Future Follow-up

Item & Location

Hazard(s) Observed

Priority

Recommended Action

Responsible Person

Action Taken

Date

Copies to: __________________________________ __________________________________ __________________________________

Inspected by: _______________________________ _______________________________ _______________________________

Managers Signature: _____________________________________________

Page 319 of 421 [Company Name] Accident Prevention & Safety Manual

Equipment/Vehicle Inspection Checklist

Date: ____________ Operator: __________________________________ Unit: ___________________

Rating Legend: N.A. = Not applicable to this unit M = Passed but maintenance required P = Passed in good working condition R = Rejected, replacement necessary before returning to service N.B.: In conjunction with this form, fill out a Maintenance Record Form and submit the two together to the office. ITEM
Driver's Compartment ___ Sun Visors ___ Windshield Wipers ___ Side Windows ___ Pedal Pads ___ Seats and Seatbelts ___ Speedometer ___ Compressor Build ___ Air Leakage ___ Horn and Switches ___ Windshield Defroster ___ Beam Indicator ___ Fire Exit ___ Accelerator Pedal and Air Throttle ___ Compressed Air ___ Steering, Column Security and Power Assist ___ Mirrors ___ Windshield ___ Instrument Lamps ___ Hazard Warning Kit ___ Air Pressure Gauge ___ Steering Travel ___ Clutch Disengagement Body Exterior ___ Headlamp Operation/Aim ___ Tail Lamps ___ Marker Lamps ___ Trailer Hitch ___ Tire Pressure ___ Trailer Cord ___ Glad Hands and Air Systems ___ Clearance Lamps ___ Stop Lamps ___ Hazard Lamps ___ Secondary Attachments ___ Paint ___ Headache Rack or Chain Rack ___ Reservoirs, Brackets and Straps ___ Identification Lamps ___ Turn Signal Lamps ___ Reflex Reflectors ___ Fenders/Mud Flaps ___ Air Lines ___ Body, Doors, Bumpers and Cabs

REMARKS/CONDITION

Page 320 of 421 [Company Name] Accident Prevention & Safety Manual

Equipment/Vehicle Inspection Checklist Continued ITEMS

Under the Hood ___ Hood ___ Power Steering System ___ Exhaust System ___ Air Filter ___ Cooling System ___ Air Compressor Belt ___ Fuel Pump and System ___ Fan and Belt ___ Windshield Washer Pump and Container ___ Air Compressor ___ Battery and Wiring ___ Carburetor ___ Distributor Undercarriage ___ Transmission ___ Steering Box ___ Cotter Pins ___ Tie Rod Ends ___ Shock Absorbers ___ Oil Pan ___ Drag Link ___ Tie Rod ___ Frame Rails ___ Springs ___ Muffler ___ Pitman Arm ___ Differential ___ Suspension ___ Axles Brakes, Tires and Wheels ___ Brake Components ___ Spring Caging Bolts ___ Disc Brakes ___ Reservoirs and Valves ___ Wheel Bearings ___ Proportioning Valve ___ Brake Camshafts and Travel ___ U-Joint ___ Brake Drum Condition ___ Brake Lines and Hoses ___ Tire Pressure ___ Vacuum System, Reserve Pump Operation ___ Tire Wear ___ Road Clearance ___ Brake Lining Thickness ___ Brake Failure Indicator ___ Park and Emergency Brakes ___ Brake Operation

REMARKS/CONDITION

Equipment Passed

Equipment Not Passed

Inspector Signature: __________________________________________________

Page 321 of 421 [Company Name] Accident Prevention & Safety Manual