Safe Work Permit

SAFE WORK PERMIT

/

E – Permit

Sections 1-5, 8, 12, 13, 16 are required for all jobs

(1) BOUNDARY OF WORK (MAINTENANCE/CONTRACTOR)

Start Date
/ Start Time / Expiration Time (Max = End ofworker’s shift)
Building / Floor / Area/Room/Equipment
Operating Unit # (Where work is completed) / Maintenance Unit/Contractor (Who will perform the work) / Phone or Radio #of Maintenance Unit/Contractor
(2) HAZARDS OF WORK (MAINTENANCE/CONTRACTOR & OPERATING UNIT)
None Identified
Chemical
Flammable or Combustible Product Residue / Oxygen Deficiency
Dust/Mist/Fumes
High Pressure
Electrical / Elevated Work (>4 feet)
Restricted Egress
Excavation
Mechanical or Pinch / Noise
Heat or Cold
Asbestos
Lead / Potential To Be Struck By An Object
Slip or Trip
Other Hazardous Work/Permits In Area
Other:

(3) PPE/HAZARD CONTROLS REQUIRED (MAINTENANCE/CONTRACTOR & OPERATING UNIT)

Safety Glasses Goggles(Line Entry) Face Shield / Hard Hat Hearing Protection Fall Protection / Harness/Retrieval Line(Confined Space)X-Ray Boundary Chemical Boots / Protective Clothing Type:
Respiratory Protection Type:
Barricade Area Glove Type: Other Type:

(4) WORK DESCRIPTION (MAINTENANCE/CONTRACTOR)

Description of Work (How work will be completed - including safety precautions)

See Attached
Chemicals, Paints, or Solvents Used During Job MSDS’s Must Be Available For All Chemicals
NA
Specialty Equipment/Tools Used:
NA

(5) TYPE OF WORK (MAINTENANCE/CONTRACTOR & OPERATING UNIT)

Complete RequiredSections(1-5, 8, 12, 13, 16)for all jobs. In addition, complete the designated sections for the following types of work:
None Of These(Complete RequiredSections) Heights>4 ft/Roof/Trestle (Complete Section6)
X-Ray (Complete Section 7) / Hot Work (Complete Sections 7, 10) Other Energy Isolation (Complete Section 9)Confined Space Entry (Complete Sections9-11) / Line Entry/Line Break (Complete Sections 9, 15)Demo/Excavation/Crane (CompleteKCA Checklists)
(6) FALL PROTECTION (MAINTENANCE/CONTRACTOR & OPERATING UNIT) Complete for all Work At Heights Greater Than 4 Feet, Unguarded Roof Work, and Trestle Work
Y N
Fall Protection equipment/provision required? (“Y” for work on unguarded surfaces >4 ft above adjacent floor OR work outside confines of ladder)
Anchor points used? If yes, anchor point is: Engineered Anchor Point I-Beam Structural Steel Other:
(7) HOT WORKor X-RAY WORK (MAINTENANCE/CONTRACTOR & OPERATING UNIT) Complete for all Hot Workor X-RayWork
Type I Hot Work - Welding, grinding, burning open flame cutting Type II Hot Work - Non-rated electrical equipment
X-Ray Work / Electrical Adapter ID: Inspected prior to use: ______
(Initials)
Electrical Adapter ID: Inspected prior to use: ______
(Initials)
Y NA
Equipment is clean
Spark protection/blankets / Y NA
Hot Work signage/X-Ray barrierat workperimeter Nearest alarm, phone ORradio identified / Y NA
Area cleared of combustibles(min 35ft for Type Iwork) Fire Extinguisher available at job site (Bring 10 lb. for Type I)
Fire or X-Ray Watch assigned (Required for Type IHot Work OR X-Ray Work only.Must remain at site for 30 min [4 hrs in B-41 truss area] after Hot Work stops)
FIRE or X-RAY WATCH INFO / Name (Print) / Signature / Time In / Time Out
1st Fire or X-Ray Watch
2nd Fire or X-Ray Watch
3rd Fire or X-Ray Watch
4th Fire or X-Ray Watch
(8) PERSONNEL WORKING UNDER PERMIT (MAINTENANCE/CONTRACTOR)
I have read this permit and will ensure that its requirements are adhered to. If working conditions change, I will cease work and contact the issuer immediately.I am familiar with emergency procedures for the area where I will be working. I know the location of the closest phone, safety shower, eyewash, and fire extinguisher.
Worker Names / Organization / Contact Info (Phone/Radio#)* / I agree with the statements
above (initial below)
* Contact info required for minimum of one team member
(9) ENERGY ISOLATION (MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Complete for all LineEntry, Confined Space Entry andOther Energy Isolation
Y NA
Equipment has been properly shut down per appropriate procedure, cleaned, and prepped for energy isolation activities?
Existing equipment specific LOTO procedure followed? Procedure # (Energy Isolation Form not required if LOTO procedure is followed)
Safe Work Permit Energy IsolationForm followed? Form # (Form not required when isolating single energy sources)
All energy sources were verified by each worker that they areisolated properly prior to their work on the system? Includes walkingdown valves/pumps/etc.
Equipment energy isolation has been verified by attempting to start the equipment while in the energy-isolated state.
Personal lock applied to Lock Box for group LOTO? (See Section 11 for Confined Space Entry LOTO scenarios).
(10) ATMOSPHERIC MONITORING – INITIAL and PERIODIC (MAINTENANCE/CONTRACTOR & OPERATING UNIT) Complete for all Hot Work, orConfined Space Entry
All Work: / 1. Atmospheric testing personnel (minimum of 2) must be trained in the use of
appropriate meters and allow all workers the opportunity to observe tests.
2. Both parties must conduct separate BUMP tests, but may use the same meter.
3. Acceptable BUMP ranges are noted in the table below. / 4. Conduct tests of work area as close as possible to work times.
5. Conduct tests in nearby trenches/drains/etc.
6. When testing work area for flammables, confirm <2.0 % of LEL.
7. Re-test required if re-entering space or work area is vacated.
Confined Space Entry: / 1. Continuous monitoring of Oxygen(O2),Carbon Monoxide(CO),Hydrogen Sulfide(H2S) & Flammables required for sewer entry.
2. Continuous monitoring required if Oxygen levels could be depleted.
3. When testing work area for Oxygen, confirm 19.5% - 23.5% Oxygenin the area.
4. BUMP test and monitor for toxic vapors if potentially toxic atmospheres will be entered.*
BUMP Tests
Results must be within range Operating Unit Maint/Contr. / AREA MONITORING
Test / InitialTests Of Work Area
Test 1 Test 2 / Re-Test 1
Time:______ / Re-Test 2
Time:______ / Re-Test 3 Time:______ / Re-Test 4 Time:______ / Re-Test 5 Time:______
Oxygen
18.5% -19.2% / Oxygen
18.5% -19.2% / Oxygen-Top / CS / CS / CS / CS / CS / CS / CS
Oxygen-Bottom / CS / CS / CS / CS / CS / CS / CS
Flammable
27% - 33% LEL / Flammable
27% - 33% LEL / Flammable-Top / CS / CS / CS / CS / CS / CS / CS
Flammable-Bottom / HW / CS / HW / CS / HW / CS / HW / CS / HW / CS / HW / CS / HW / CS
Toxic
If Applicable* / Toxic
If Applicable* / *Toxic-Top / CS / CS / CS / CS / CS / CS / CS
*Toxic-Bottom / CS / CS / CS / CS / CS / CS / CS
/ Meter ID
/ Name or Initials
Unit/Organization / Operating
Unit / Maintenance or Contractor
* If toxic vapor BUMP test or monitoring is required, list toxic material: ______and allowable limit: ______. Consult EHS for toxic vapor questions.
(11) CONFINED SPACE ENTRY (MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Complete for all Confined Space Entry
ENTRY SUPERVISOR(S)
Name (Print)
1. ______
Initial to indicate approval to enter: ______
2. ______
Initial to indicate approval to enter: ______
3. ______
Initial to indicate approval to enter: ______/ ATTENDANT(S)
Name (Print)
1. ______
2. ______
3. ______
4. ______
5. ______
6. ______
7. ______/ ENTRANT(S)
Name (Print)
1. ______
2. ______
3. ______
4. ______
5. ______
6. ______
7. ______/ Personal Locks
(NA if using Energy Isolation Form)
Applied
Communication between attendant and entrants via: Radio Voice Other:______
Radio communication w/Fire Station established maintained during entry______(Attendant init.) / Falcon Horn was tested for functionality: ______(Attendant initials) Is forced ventilation required during entry? Yes No
(12) ADDITIONAL PRECAUTIONS/INSTRUCTIONS (OPERATING UNIT)
Complete if there is a need to describe any Specific Hazards, waste disposal info, and/or other requirements for the work
(13) PERMIT APPROVAL (OPERATING UNIT) / (14) UNIT REPRESENTATIVE CHANGE (OPERATING UNIT)
Y NA
Joint walkthrough with operating unit and worker rep required after job
Notified other areasof work (Required for Hot Work and X-Ray Work)
Unit Representative Name Signature Date/Time
Radio #: ______/ If applicable, the outgoing unit representative has communicated the details of this permit/job to an incoming unit representative
Incoming Unit Representative Signature Date/Time
Radio #: ______
(15) LINE INTEGRITY CHECKLIST (MAINTENANCE/CONTRACTOR & OPERATING UNIT)
NAComplete for all process and service piping after Line Entry is complete and system is being restored
Y N
Is system returned to a condition allowing pressure testing?
If Yes, Maintenance/Contractor may move on to Section 16, and the operating unit willcomplete the remainder of section 15.If No, finish Section 15 together.
Y N NA
Pressure check will be performed
Pressure check not possible-use following precautions
Spill kit is on hand available / Y NA
New gaskets used
Flanges/connections are tight
Drain/bleed valves are closed / Y NA
Operating unit positioned valves properly
Established and maintained flow/pressure
Confirmed integrity of system (no leaks)
Fugitive Emissions requirements: Operations called 3-6444 for OVA monitoring on tagged equipment. Pressure tests completed on Pressure Test Trains
(16) PERMIT COMPLETION (MAINTENANCE/CONTRACTOR & OPERATING UNIT)
Maintenance/Contractor To Address The Following Items Prior To Sign-Off
Y NA
All work relating to this job is completed.(NA = Work will resume later)
Equipment removed from area (Adapters, Barriers, X-RaySources,etc.)
Notification made to effected workers that work is complete (Required
after X-Ray work. Must notify Fire Station after Confined Space Entry)
All personal locks are removed from the equipment and/or lock box. / Final Sign-off To Close Out This Safe Work Permit
______
Maintenance/Contractor Signature Date Time
_ ____
Unit Representative Signature Date Time

Send completedpermit to Kalamazoo EHS at PORT-41-16

Form#: GM00037-E Revised: Jan 09 2009 EMERGENCY PHONE #: 1-2-3 (Cell Phone: 833-4799) SPILL EMERGENCY PHONE #: 3-3800 (833-3800)