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Foremark Performance Chemicals
Foremark Performance Chemicals
Mark Abston

Foremark Performance Chemicals

Safe Work Permit

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Free Foremark Performance Chemicals Checklist

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Title Page

  • LOGO.jpg

  • This permit is valid only for the time, work, tools, equipment, and personnel listed.

  • Job Description

  • Permit Number

  • Date and Time Prepared

  • Name of Contractor

    • Toro
    • ISC
    • EFX
    • Bobcat Crane
    • Houston Compressor Services
    • United Rental
    • Sunbelt Rental
    • Deer Park Rental
    • Specialty Rail Services
    • C & C Rail Construction
    • Top Water Solutions
    • Puffer Swieven
    • Vallen
    • Sneider Electric
    • Servomex
    • Mettler Toledo
    • Cooling Towers of Texas
    • Industrial Scale
    • Other

  • Enter name of contractor

  • Contractor Representative Name

  • Representative Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Additional Contractor

  • Contractor Name

  • Contractor Signature

  • Permit Expiration Date and Time

General Work Permit (No power source required)

  • General Work Permit (No power source required)

  • Required tools

    • Hand tools
    • Drill
    • Welder
    • Grinder
    • Powered tools, electric or pneumatic
    • Cutting torch

  • One of the selected "Required tools" is not allowed for this type of permit.

    R.png

  • Will there be an opening of equipment or piping?

  • Has the equipment or piping been isoloated?

  • Stop and review the appropriate P&ID before proceeding.

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  • Has the equipment or piping been proven clear of chemicals?

  • A "First Break" watch is required.

  • Name of "First Break" watch?

  • Will the equipment or line require a purge?

  • Type of purge

  • Has a Lockout/Tagout been completed?

  • Was a lock box issued?

  • Enter lock box number

  • Is a Lockout/Tagout required?

  • Stop and review the appropriate P&ID for lockout/tagout.

    R.png

  • Is a scaffold/manlift/ladder required?

  • Has an inspection been completed?

  • An inspection must be completed before continuing.

    R.png

  • Is Special PPE Required

  • Chemical goggles

  • Dust masks

  • Full face respirator

  • Cartridge Type

  • 1/2 face respirator

  • Cartridge Type

  • Supplied air respirator required?

  • Is it verified working?

  • Verify to be working before proceeding.

    R.png

  • O2 Bottle / Breather Box verified working?

  • Verify to be working before proceeding.

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  • Approved Chemical gloves

  • Impact gloves

  • Slicker required for first break only

  • Paper (Tyvek) coveralls

  • Body harness / Tie-off

  • Rubber boots

  • Metatarsal boots

  • Other PPE

  • List other PPE.

  • Appropriate SDS available

  • Stop and locate SDS before continuing.

    R.png

  • Affected personnel notified

  • Please notify affected personnel before continuing.

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  • Is the contaminated area secure?

  • PROCEED WITH CAUTION TO AVOID EXPOSURE IN AN UNSECURED AREA.

    CAUTION.jpg

  • Hot Surfaces Identified and Protected

  • PROCEED WITH CAUTION AVOID CONTACT WITH UNPROTECTED HOT SURFACES.

    CAUTION.jpg

  • Barricade Tape/Safety cones in place

  • Overhead work, i.e., crane, cherry picker, etc.

  • Is the area barricaded?

  • Is an airhorn available during lift?

  • FPC Work Supervisor

    • Andrew Delgado
    • Colter Brog
    • Kenny Bell
    • Noah Abston
    • Jesse Johnston
    • Travis Alexander
    • Mark Abston
    • Erik Pitoniak
    • Cheovanny Oropeza
    • Michael Dildy

  • Area Certified Personnel

    • Jacob Holleman
    • Jake Elizondo
    • Derrick Forsythe
    • Sammy Stanfill
    • Mark Abston
    • Colter Brog
    • Noah Abston
    • Kenny Bell
    • Travis Alexander

  • Area Certified Personnel Signature

Single Signature Permit (Low energy, no cutting or drilling into process equipment)

  • Single Signature Permit (Low energy, no cutting or drilling into process equipment)

  • Required tools

    • Hand Tools
    • Grinder
    • Welder
    • Impact
    • Drill
    • Cutting torch

  • One of the selected "Required tools" is not allowed for this type of permit.

    R.png

  • Will there be an opening of equipment or piping?

  • Has the equipment or piping been isoloated?

  • Stop and review the appropriate P&ID before proceeding.

    R.png

  • Has the equipment or piping been proven clear of chemicals?

  • A "First Break" watch is required.

  • Name of "First Break" watch?

  • Will the equipment or line require a purge?

  • What type of purge?

  • List other

  • Has a Lockout/Tagout been completed?

  • Was a lock box issued?

  • Enter lock box number

  • Is a Lockout/Tagout required?

  • Stop and review the appropriate P&ID for lockout/tagout.

    R.png

  • Work from scaffolding/manlift/ladder

  • Has an inspection been completed?

  • An inspection must be completed before continuing.

    R.png

  • Is a fire extinguisher required?

  • Type of fire extinguisher?

    • Class A (Fires in ordinary combustible materials, such as wood, cloth, paper, rubber, and many plastics)
    • Class B (Fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases)
    • Class C (Fires that involve energized electrical equipment)
    • Class D (Fires in combustible metals, such as magnesium, titanium, zirconium, sodium, lithium, and potassium)

  • Is Special PPE Required

  • Chemical goggles

  • Splash shield

  • Dust masks

  • Full face respirator

  • Cartridge Type

  • 1/2 face respirator

  • Cartridge Type

  • Supplied air respirator required?

  • Is it verified working?

  • Verify to be working prior to work.

    R.png

  • O2 Bottle / Breather Box verified working?

  • Verify to be working prior to work.

    R.png

  • Approved Chemical gloves

  • Impact gloves

  • Slicker required for first break only

  • Paper (Tyvek) coveralls

  • Body harness / Tie-off

  • Rubber boots

  • Metatarsal boots

  • Personal monitor

  • List monitor being used.

  • Other PPE

  • List other PPE.

  • Appropriate SDS available

  • Stop and locate SDS before continuing.

    R.png

  • Affected personnel notified

  • Please notify affected personnel before continuing.

    R.png

  • GFI Tested (if applicable)

  • Is the contaminated area secure?

  • PROCEED WITH CAUTION TO AVOID EXPOSURE IN AN UNSECURED AREA.

    CAUTION.jpg

  • Hot Surfaces Identified and Protected

  • PROCEED WITH CAUTION TO AVOID CONTACT WITH UNPROTECTED HOT SURFACES.

    CAUTION.jpg

  • Barricade Tape/Safety cones in place

  • Overhead work, i.e., crane, cherry picker, etc.

  • Are barricades in place?

  • Is an air horn available during the lift?

  • Atmosphere Test

  • LEL%

  • Enter LEL%

  • LEL% IS AT AN UNSAFE LEVEL.

    R.png

  • O2%

  • Enter O2%

  • O2% IS AT AN UNSAFE LEVEL

    R.png

  • O2% IS AT AN UNSAFE LEVEL

    R.png

  • CO PPM

  • Enter CO PPM

  • CO PPM IS AT AN UNSAFE LEVEL.

    R.png

  • H2S PPM

  • Enter H2S PPM

  • H2S PPM IS AT AN UNSAFE LEVEL

    R.png

  • Atmosphere Test is required for this permit type.

    R.png

  • Specify Hazards

  • List Hazards

  • FPC Work Supervisor

    • Andrew Delgado
    • Colter Brog
    • Kenny Bell
    • Noah Abston
    • Jesse Johnston
    • Travis Alexander
    • Mark Abston
    • Erik Pitoniak
    • Cheovanny Oropeza
    • Michael Dildy

  • Area Certified Person

    • Jacob Holleman
    • Jake Elizondo
    • Derrick Forsythe
    • Sammy Stanfill
    • Mark Abston
    • Colter Brog
    • Noah Abston
    • Kenny Bell
    • Travis Alexander

  • Area Certified Person Signature

Dual Signature Permit (High energy, drilling or cutting into process equipment)

  • Dual Signature Permit (High energy, drilling or cutting into process equipment)

  • Tools required?

  • Will there be an opening of equipment or piping?

  • Has the equipment or piping been isoloated?

  • Stop and review the appropriate P&ID before proceeding.

    R.png

  • Has the equipment or piping been proven clear of chemicals?

  • A "First Break" watch is required.

  • Name of "First Break" watch?

  • Will the equipment or line require a purge?

  • Will there be an opening of equipment or pipe?

  • Has the equipment or piping been isolated?

  • Stop and review the appropriate P&ID before proceeding.

    R.png

  • Will the equipment or piping require a purge?

  • Type of purge?

  • List other

  • Has the equipment or piping been proven clear of chemicals?

  • Watch available for "First Break"

  • Name of "First Break" watch

  • Atmosphere Test

  • LEL%

  • Enter LEL%

  • LEL% IS AT AN UNSAFE LEVEL

    R.png

  • O2%

  • Enter O2%

  • O2% IS AT AN UNSAFE LEVEL

    R.png

  • O2% IS AT AN UNSAFE LEVEL

    R.png

  • CO PPM

  • Enter CO PPM

  • CO PPM IS AT AN UNSAFE LEVEL

    R.png

  • H2S PPM

  • Enter H2S PPM

  • H2S PPM IS AT AN UNSAFE LEVEL

    R.png

  • Hazards (Specify)

  • This type of permit requires an atmosphere test.

    R.png

  • Work from scaffolding/manlift/ladder

  • Is inspection up-to-date?

  • Is Special PPE Required

  • Chemical goggles

  • Welding hood/cutting goggles

  • Splash shield

  • Impact shield

  • Full face respirator

  • Cartridge Type

  • 1/2 face respirator

  • Supplied air respirator

  • Verified working?

  • Verify working before work.

    R.png

  • O2 Bottle/ Breather box verified working?

  • Verify working before work.

    R.png

  • Chemical gloves

  • Welding gloves (Leather)

  • Impact gloves

  • Slicker required for first break only

  • Paper (Tyvek) coveralls

  • Body harness / Tie-off

  • Rubber boots

  • Metatarsal boots

  • Is a fire extinguisher available?

  • Type of fire extinguisher?

    • Class A (Fires in ordinary combustible materials, such as wood, cloth, paper, rubber, and many plastics)
    • Class B (Fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases)
    • Class C (Fires that involve energized electrical equipment)
    • Class D (Fires in combustible metals, such as magnesium, titanium, zirconium, sodium, lithium, and potassium)

  • A PROPER FIRE EXTINGUSHER SHOULD BE READILY AVAVILABE WHILE PERFORMING HOT WORK.

    CAUTION.jpg

  • Personnel Monitor Required?

  • List required monitor

  • Other PPE required

  • List other PPE

  • Barricade Tape/Safety cones in place (if applicable)

  • Hot Surfaces Identified and Protected

  • PROCEED WITH CAUTION TO AVOID CONTACT WITH UNPROTECTED HOT SURFACES

    CAUTION.jpg

  • Contaminated areas identified & protected

  • PROCEED WITH CAUTION TO AVOID EXPOSURE IN UNPROTECTED AREAS

    CAUTION.jpg

  • GFI Tested (if applicable)

  • FPC Work Supervisor

    • Andrew Delgado
    • Colter Brog
    • Kenny Bell
    • Noah Abston
    • Jesse Johnston
    • Travis Alexander
    • Mark Abston
    • Erik Pitoniak
    • Cheovanny Oropeza
    • Michael Dildy

  • Area Certified Person

    • Jacob Holleman
    • Jake Elizondo
    • Derrick Forsythe
    • Sammy Stanfill
    • Mark Abston
    • Colter Brog
    • Noah Abston
    • Kenny Bell
    • Travis Alexander

  • Area Certified Person Signature

  • Second Certified Person

    • Mark Abston
    • Erik Pitoniak
    • John Myers
    • Mike Gonzales
    • Robert Taylor
    • Tyler Smith

  • Second Certified Person Signature

Confined Space Entry (Dual Signature Permit)

  • Confined Space Entry (Is large enough and so configured that an employee can bodily enter and perform assigned work;<br>Has limited or restricted means for entry or exit (for example, tanks, vessels, silos, storage bins, hoppers, vaults, and pits are spaces that may have limited means of entry); and<br>Is not designed for continuous employee occupancy)

  • Will there be an opening of equipment or piping?

  • Has the equipment or piping been isolated?

  • Stop and review the appropriate P&ID before proceeding.

    R.png

  • Will the equipment or piping require a purge?

  • Type of purge?

  • Enter other.

  • Has the equipment or piping been proven clear of chemicals?

  • Watch available for "First Break"

  • Name of "First Break" watch

  • Atmosphere Test

  • LEL%

  • Enter LEL%

  • LEL% IS AT AN UNSAFE LEVEL.

    R.png

  • O2%

  • Enter O2%

  • O2% IS AT AN UNSAFE LEVEL.

    R.png

  • O2% IS AT AN UNSAFE LEVEL.

    R.png

  • CO PPM

  • Enter CO PPM

  • CO PPM IS AT AN UNSAFE LEVEL.

    R.png

  • H2S PPM

  • Enter H2S PPM

  • H2S PPM IS AT AN UNSAFE LEVEL.

    R.png

  • Hazards (Specify)

  • Area Certified Person

    • Jacob Holleman
    • Jake Elizondo
    • Derrick Forsythe
    • Sammy Stanfill
    • Mark Abston
    • Colter Brog
    • Noah Abston
    • Kenny Bell
    • Travis Alexander

  • Second Certified Person

    • Mark Abston
    • Erik Pitoniak
    • John Myers
    • Mike Gonzales
    • Robert Taylor
    • Tyler Smith

  • This type of permit requires an atmosphere test.

    R.png

  • Work from scaffolding/manlift/ladder

  • Is inspection up-to-date?

  • Is Special PPE Required

  • Chemical goggles

  • Welding hood/cutting goggles

  • Splash shield

  • Impact shield

  • Full face respirator

  • Cartridge Type

  • 1/2 face respirator

  • Supplied air respirator

  • Verified working?

  • Verify working before proceeding.

    R.png

  • O2 Bottle/ Breather box verified working?

  • Verify working before proceeding.

    R.png

  • Chemical gloves

  • Welding gloves (Leather)

  • Impact gloves

  • Slicker required for first break only

  • Paper (Tyvek) coveralls

  • Body harness / Tie-off

  • Rubber boots

  • Metatarsal boots

  • Is a fire extinguisher required?

  • Type of fire extinguisher?

    • Class A (Fires in ordinary combustible materials, such as wood, cloth, paper, rubber, and many plastics)
    • Class B (Fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases)
    • Class C (Fires that involve energized electrical equipment)
    • Class D (Fires in combustible metals, such as magnesium, titanium, zirconium, sodium, lithium, and potassium)

  • Personnel Monitor Required?

  • List required monitor

  • Other PPE required

  • List other PPE

  • Barricade Tape/Safety cones in place

  • Is there an emergency plan?

  • An emergency plan is required before proceeding.

    R.png

  • List other emergency plan

  • Hot Surfaces Identified and Protected

  • PROCEED WITH CAUTION TO AVOID MAKING CONTACT WITH UNPROTECTED HOT SURFACES.

    CAUTION.jpg

  • Contaminated areas identified and secured.

  • PROCEED WITH CAUTION TO AVOID EXPOSURE IN AN UNSECURED AREA

    CAUTION.jpg

  • GFI Tested (if applicable)

  • FPC Work Supervisor

    • Andrew Delgado
    • Colter Brog
    • Kenny Bell
    • Noah Abston
    • Jesse Johnston
    • Travis Alexander
    • Mark Abston
    • Erik Pitoniak
    • Cheovanny Oropeza
    • Michael Dildy

  • Area Certified Person

    • Jacob Holleman
    • Jake Elizondo
    • Derrick Forsythe
    • Sammy Stanfill
    • Mark Abston
    • Colter Brog
    • Noah Abston
    • Kenny Bell
    • Travis Alexander

  • Area Certified Person Signature

  • Second Certified Person

    • Mark Abston
    • Erik Pitoniak
    • John Myers
    • Mike Gonzales
    • Robert Taylor
    • Tyler Smith

  • Second Certified Person Signature

Excavation (Dual Signature Permit)

  • Excavation

  • Tank/Vessel entry

  • Equipment isolated

  • Rescue kit available

  • Bottle watch

  • Name of bottle watch

  • Air horn available

  • Hole watch

  • Name of hole watch

  • Radio available

  • Rescue plan

  • Explain evacuation plan.

  • Excavation shored/sloped/trench box

  • Space ventilated

  • Attendant present

  • Atmosphere Test

  • LEL%

  • LEL% IS AT A DANGEROUS LEVEL. DO NOT PROCEED.

    R.png

  • O2%

  • Enter O2%

  • O2% IS AT AN UNSAFE LEVEL

    R.png

  • O2% IS AT AN UNSAFE LEVEL

    R.png

  • CO PPM

  • Enter CO PPM

  • CO PPM IS AT AN UNSAFE LEVEL

    R.png

  • H2S PPM

  • Enter H2S PPM

  • H2S IS AT AN UNSAFE LEVEL

    R.png

  • Hazardous (Specify)

  • Job Hazard Concerns

  • Explain

  • FPC Work Supervisor

    • Andrew Delgado
    • Colter Brog
    • Kenny Bell
    • Noah Abston
    • Jesse Johnston
    • Travis Alexander
    • Mark Abston
    • Erik Pitoniak
    • Cheovanny Oropeza
    • Michael Dildy

  • Area Certified Person

    • Jacob Holleman
    • Jake Elizondo
    • Derrick Forsythe
    • Sammy Stanfill
    • Mark Abston
    • Colter Brog
    • Noah Abston
    • Kenny Bell
    • Travis Alexander

  • Area Certified Person Signature

  • Second Certified Person

    • Mark Abston
    • Erik Pitoniak
    • John Myers
    • Mike Gonzales
    • Robert Taylor
    • Tyler Smith

  • Second Certified Person Signature

Job Completion / Permit Sign-Off

  • Job completed, area cleaned and inspected

  • Explain the failure.

  • Worker, Contractor, or Crew Representative Name

  • Worker, Contractor, or Crew Representative Signature

  • Area Certified Person Name

    • Jacob Holleman
    • Jake Elizondo
    • Derrick Forsythe
    • Sammy Stanfill
    • Mark Abston
    • Colter Brog
    • Noah Abston
    • Kenny Bell
    • Travis Alexander

  • Area Certified Person Signature

Foremark Performance Chemicals
Mark Abston

Foremark Performance Chemicals

Safe Work Permit

Use this Template
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.

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