Safe Work Permit TX Whiskey

Project Name:

Location:

Date of pick:

Description of load:

Weight of load:

Lbs. Length of load:

ft. Width of Load:

ft. Lift height:

Crane Operator:

Qualifications:

Lift Supervisor:

Qualifications:

Rigger:

Qualifications:

Hoisted personnel (if applicable):

Choose all that apply

• Lifting greater than 75% of the rated capacity

• Lift involving more than one crane

• Lift over occupied structures or in tight quarters

• Blind lift (out of view of the operator)

• Hoisting personnel

• Lift involving non-routine rigging techniques

• Lift where the center of gravity may change

• Lifting submerged loads

• Lift near power lines

Other (describe):

Manufacturer:

Model:

Mobile Crane Capacity (lbs):

Over Rear:

Over Front:

Over Side:

Route of Travel:

Tower Crane Capacity (lbs):

Boom length:

Maximum Radius(ft):

Jib length:

Load block:

# of sheaves:

Size:

Weight:

Secondary block:

# of sheaves:

Size:

Weight:

Hoist Rope Diameter:

Maximum rated capacity for lift radius and boom angle (lbs)

Maximum crane load for lift radius and boom angle (lbs)

Lift rated capacity (%)

Load weight (lbs):

Source of load weight:

Load weigh confirmation:

Total rigging weight(blocks, lifting beam, slings, shackles, rope, etc.) in lbs:

Total load weigh (load & rigging) in lbs.

Choose all that apply

• Standard signaling

• Voice

• Radio

• Telephone

Other:

Number:

Diameter

Length:

Capacity (lbs):

Number:

Size:

Type:

Capacity (lbs):

Ground Conditions:

Outrigger Position:

Degree of level:

Maximum allowable windspeed in mph:

Site windspeed range in mph:

Method of windspeed confirmation:

Site weather conditions:

Proximity to other workers:

Proximity to power lines:

Obstacles or obstructions to lift or swing:

Proximity to other hazards

Daily inspection date:

Competent person:

Annual inspection date:

Competent person:

Date:

Competent person:

Project Manager/Engineer:

Date:

Supervisor:

Date:

Crane Operator:

Date:

Completion/Cancellation Date

Completion/Cancellation Time

Diagram Crane & Load Placement (draw in space below or attach a copy)

Diagram Rigging Configuration (draw in space below or attach a copy)

Name

Signature

Double isolation required for Chemical, asphyxiating gas & Steam

• Yes
• No
• N / A

Do you understand the risk of the material in the line/equipment

• Yes
• No
• N / A

Is adequate isolation of the hazardous material possible

• Yes
• No
• N / A

Is adequate decontamination of the hazardous material possible

• Yes
• No
• N / A

Have the lines been drained

• Yes
• No
• N / A

Have the lines been flushed with water

• Yes
• No
• N / A

Lines purged with nitrogen (where available)

• Yes
• No
• N / A

Have the lines been depressurized

• Yes
• No
• N / A

Define proper PPE required:

Is steam tracing off

• Yes
• No
• N / A

Did you obtain authorization to break the line (signed SWP)

• Yes

• No

Area personnel notified

• Yes
• No
• N / A

Area restricted access/barricades

• Yes
• No
• N / A

Executer the job (wearing defined PPE from step 4)

• Yes
• No
• N / A

Person Preparing lines for break

Person Executing line break

Area Manager/ Supervisor

What

How

Where

The task has been reviewed and it is not possible to eliminate WAH?

• Yes
• No
• N / A

Choose all that apply

• Travel Restraint, Falls are prevented- PPE Limits Travel

• Fall Arrest, does not prevent fall- Limits Fall

• Articulating boom lift- Fall restraint system required at all times

• Scaffolding (stationary) Must have valid tag, must be designed

• Scaffolding (portable/rolling) Fall protection with safe access

• Scissor Lift- (requires 100% tie off) may need two lanyards on for basket and one for exit

• Work Positioning System, continuous tension. restrained by PPE

• Guardrail System (passive fall protection)

• Other

If outside - is weather suitable?

• Yes
• No
• N / A

Is work surface level?

• Yes
• No
• N / A

Work beneath is controlled?

• Yes
• No
• N / A

Overhead power lines Present?

• Yes
• No
• N / A

Choose all that apply

• Fixed anchor point

• Fixed ladder grab

• Mobile anchor point (Lift, I-Beam runner, anchor strap, roof carts etc.)

• Restraint lanyard

• Retractable lanyard

• Shock absorbing lanyard ( not to be used less that 20ft from lower level)

• Work Positioning system

• 100% Tie off (exiting a lift, roof access, etc.)

• Physical control in place for restricted access zone (overhead work)

• Other

Fall distance calculation has been determined?

• Yes
• No
• N / A

Rescue plan has been completed?

• Yes
• No
• N / A

Are there skylights present? – if yes must be guarded to prevent fall through

• Yes
• No
• N / A

Do you have a communications Plan?

• Yes
• No
• N / A

Are you working within 6' of the roofs edge?

• Yes
• No
• N / A

Is temporary roof guard needed and in place?

• Yes
• No
• N / A

QUALIFIED PERMIT APPROVER SIGNATURE

TIME ISSUED

TIME EXPIRES

PERMIT RECEIVER SIGNATURE

TIME ISSUED

TIME EXPIRES

Name of person performing WAH

Valid training documentation

Area in which work is to be performed:

Date

Time

Starting

Ending

Brief description of work to be performed:

Pernod Contact/Designee Signature

Printed Name

Dept./Company

Phone No.

Excavation Competent Person Signature

Printed Name

Dept./Company

Phone No.

Contractor Representative Signature

Printed Name

Dept./Company

Phone No.

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

SIGNATURES of UTILITY REPRESENTATIVES

Date

SIGNATURES OF PERNOD DESIGNEE

Date

Comments

Choose all that apply

• 1. There are no lines not identified on the drawings

• 2. There are no surface obstructions

• 3. There are no overhead obstructions

• 4. There is no traffic and/or other work in the immediate area

• 5. Safety warning systems for mobile equipment are working

• 6. There is no hazardous atmosphere potential

• 7. There is no water accumulation hazard

• 8. The stability of adjacent structures are not threatened

• 9. Lock-out tag-out procedures are not necessary

• 10. No other potentially hazardous conditions are present

• 11. There are no hazards the equipment operator has not been informed of.

If any of the above have NOT been selected write a description of corrective actions to be taken specific to this excavation.

12. Has proper access and egress been established and maintained?

• Yes
• No
• N / A

13. Are trench workers protected from falling debris and equipment?

• Yes
• No
• N / A

14. Has the trench been inspected prior to entry?

• Yes
• No
• N / A

15. Is the excavation barricaded properly?

• Yes
• No
• N / A

16. Has the excavation material been place a minimum of 3 feet from the excavation?

• Yes
• No
• N / A

17. Has sloping been completed properly (one and one half to one)? Benching/or shielding in use as appropriate for soil

• Yes
• No
• N / A

18. Are materials and equipment properly maintained?

• Yes
• No
• N / A

19. If a “confined space permit” is required, is it complete?

• Yes
• No
• N / A

20. If a “hot work permit” is required, is it complete?

• Yes
• No
• N / A

Last Name

Date

Last Name

Date

Oxygen % (19.5-23.5%)

Flammability % LEL (0% required)

Other test (list)

Type of meter

Time

Results

Initials

Fire Watch

• Yes
• No
• N / A

Type

• Dry chemical

• CO2

• H2O

How Many

Other

Special PPE to be worn

Choose all that apply

• Area and surrounding conditions are inspected

• All combustibles are located beyond 35' and protected

• Sloping and shoring are required

• Automatic sprinklers are in service

• Confined space entry permit is required

• asbestos is involved

• The area below elevated hot work is clear of combustibles or protected

• Barriers are in place for area below elevated hot work

• Sewers, tanks, open pipes, and valves have been checked with an LEL meter and protected

Special precautions

Equipment has been isolated by:

Choose all that apply

• Blanking/Blinding off

• Double block and bleed

• Disconnecting

• Controls and energy sources (LOTO)

• Flammable process materials (liquids, gases, etc.) have been removed from equipment

The equipment has been purged/cleaned by:

Choose all that apply

• Flushing

• Steam

• Air Ventilation

TX Whiskey Contact Name:

Phone number:

Contractor Supervision

• Yes
• No
• N / A

Supervisor Name

Company Name

Crew size

Date

Time

Date

Time

Permit issued by

Signature