all signatures are required prior to initial confined space entry. authorized entry print...

All Signatures are Required PRIOR to INITIAL confined space entry.

Authorized Entry Print Name Signature Date

Permit Holder

Permit Issuer

Shift Supervisor

Confined Space Attendant

Job Hazards Y Standard Controls Job Hazards Y Standard Controls PPE Req’dAccess & Egress Housekeeping, Walkways, Stairs Manual Handling Assessment ,& Equipment Standard (SSP-0011) YActivities-Proximity of Others Communications, Barriers, Permit Moving Parts Covers, Isolation, & Maintenance Full Face Shield Adverse Weather Stop Work & Take Refuge Noise Insulation, Hearing Protection, & PPE GogglesChemical Exposure MSDS Review, PPE Overhead Cables Labelling, Isolation, & Barriers Hearing ProtectionVehicle Entry Procedures, Barriers, & Permit Sharp Edges Covers, PPE, & Equipment Inspections Fall Protection YElectricity Isolation, LOTO Slips, Trips & Falls Housekeeping, & PPE Chemical Gloves Exposure to Fuels PPE Static Electricity Grounding, Chemical Suit Fatigue Rest Periods, Refreshments Trapped Pressure Venting, Draining, & PPE Respirator ½ faceFire & Explosion Gas Testing & Isolation Vehicle Traffic Hi-Vis Clothing, Speed Limit, & Signs Respirator Full FaceFumes & Dust Filter Mask, Eye Protection Underground Cables CAT Testing, Labelling, & Barriers Air Supplied Hood/LineSoil/Water Contamination Isolation Hot Liquid Procedures & PPE SCBASecondary Containment Procedures Working at Height Hand Rails, Harness, & Life-Line Personal H2S Monitor YHot Surfaces Procedures & PPE Working Over Water Life Jacket, & Safety Boat, Other -- Nature (insects, snakes…) Awareness, Remove, PPE Inside Falling Material Scaling walls, shoring up, securingInside Temperature Check Temp, Ventilation, A/C

Meraux Refinery Confined Space Work PermitPermit Number:

Information to be completed by Permit Holder Company: Meraux Refinery

Contractor Name

Area/Unit Permit Holder: Date:

Equipment # # Persons:Work Order # (s)

Scope of Proposed Task:

Information to be completed by Permit Issuer. (Must be Chief Operator)

Work Description:

Previous Product in Vessel: MSDS Checked Yes No Comment:

Equipment Pre-Work Req’d Done Equipment Pre-Work Req’d Done Area Preparation Req’d DoneLOTO Procedures Followed Y Lock Box Number: Safety Department Notified Y• Blinded/Disconnected Aspirating / Fans / Air Flow Rescue Services Available Y• Equipment Opened/Depressurized • Grounded / Bonded Trained Entry Attendant Y• Valves-Closed/Tagged/Chained/Locked • Main Air Supply Valves Tagged • Evacuation Horn Y• Electrically locked / tagged out • Natural Draft • Orange Vest Y• Field Test / Attempt to Energize-start Radioactive Source Secure • Sign in/Sign out log YBlinds Verified & Blind-List initialed Y Internal Lighting • Contact:Vessel Decontamination • Low Volt 12 V lights • Retrieval System • Water Washed • 120 V w/ GFCI • Life Line• N2 Purged • Inert Entry Procedure • Continuous air monitor• Steamed • Confined Space Signs Posted Y Bottle Watch / Additional Standby

No Date Time %LEL Oxygen H2S CO Other Serial No Meraux Qualified Person:1

2

3

4

Permit EndWork

CompletedWork Site in

Safe Condition Print Name Signature DateCSE Permit ReviewWithin 12 months

Permit Holder Yes No Yes No By:

Unit Operator Yes No Yes No Date:

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.

Additional Controls Required: Special Instructions:

All Signatures are Required PRIOR to EXTENDING permit up to 12 hours.

Authorized Entry Print Name Signature Date

Permit Holder

Permit Issuer

Shift Supervisor

Confined Space Attendant