Safe Work Permit Form

CONFINED SPACE ENTRY HOT WORK EXCAVATION ELECTRICAL WORK

PART I WORK DETAILS
Company SNC-Lavalin Sub-Contractor Crew Size(#): Company:
Date Issued: D M_ Y Time Issued: Date Expired: D M __Y __Time: __________________________
Extended Date: D M Y Extended Time: Extended by:
Emergency Meeting Point(s): Location:
Description of work to be done:
Additional Documentation Needed (Attach): JSA Electrical Diagram Utility Locates Training Records P&ID Inspection Records
Lift Plan Engineered Critical Lift Plan MSDS Soil Characterization Equipment Calibration Rescue Plan Traffic Control Plan
PART II FOR HOT WORK ONLY (Mark each box as applicable)
Welding Cutting Brazing Torching Explosive Actuated Tools
Grinding, Drilling or Soldering (If flammables are present) Other (Describe):
PART III HAZARDS (Mark each box as applicable)
Yes No N/A Yes No N/A Yes No N/A
Hazardous Chemicals O/H power Ignition source
Live electricity U/G power Flammables
SO2 U/G piping Combustibles
Low O2 U/G gas Poor/extreme lighting
LEL Slips, trip and falls Extreme cold / heat
High pressure Congestion / obstruction Collapsing soil/spoils
Airborne hazards Public interaction Radiation
Yes No N/A
Pinch point
Moving parts
O/H hazard
Hoisting / Lifts
Others:

PART IV CONTROL MEASURES TO MITIGATE HAZARDS (Mark each box as applicable)
Yes No N/A Yes No N/A Yes No N/A
Pre-job meeting Isolation /Lockout Welding Screen
Group notification Tagging Scaffolding
Drain equipment Air mover Flag person
Purge equipment Ventilation Grounding
Steam equipment Barricading (hard/soft) Chock wheels
Flush equipment Railing Slopping
De-energization Clearance Cut Back
Yes No N/A
Shoring
Guarding
Interlocking
Signage
Others:

PART V ADDITIONAL PERSONAL PROTECTIVE EQUIPMENT REQUIRED (Mark each box as applicable)
Yes No N/A Yes No N/A Yes No N/A
SCBA / SABA Chem-resistant gloves Life line
Full face respirator Chem-resistant boots Fall arrest
Half face respirator Goggles FR clothing
HazMat suit Face shield Hearing protection
Yes No N/A
Personal air monitor
Radio
Others:

PART VI ATMOSPHERIC MONITORING REQUIRED NOT REQUIRED

Type
Flammable
Vapours

Oxygen
SO2
Others:


Test to be repeated every (Min) Continued Monitoring
Monitoring results attached: Yes No
Monitoring Location:
Tested By (Print):
Signature: _________________________________________

Time


% LEL or PPM


Target

<5% LEL

19.5% - 23%

5 PPM

PART VII THIS DOCUMENT HAS BEEN READ, UNDERSTOOD AND AGREED BY:
Open
Permit
Permit Reviewer (EPO Supervisor):
Permit Reviewer (Outotec Supervisor):
Permit Reviewer (EPO HSE):
Permit Reviewer (Outotec HSE):
Signature / Date:___________________________
Signature / Date:___________________________
Signature / Date:___________________________
Signature / Date:___________________________



Permit Issuer: Signature / Date:
Permit Receiver: Signature / Date:
Permit Transferred to: Signature / Date:
Closed
Permit
Permit Receiver Sign-off: Signature / Date:
Permit Reviewer Sign-off (Outotec): Signature / Date:
Permit Issuer Sign-off:
Job completed Job not completed Area left safe, clean and tidy Yes No
6845.3.7.3-EN-Rev.03 _RTB-Bor Project Last printed 2013-08-01 Page 1 of 1