Safe Work Permit

Select the type of work to be performed.

Pipe or equipment opening (no hot work or confined space)
Confined space
Hot work e.g., Welding, grinding, cutting and brazing
Mobile crane (lift only)
Excavation
X-ray or ionizing radiation
Work on live, un-insulated electrical equipment over 50 volts
Un-protected work at height over 4 feet
Open handling of hazardous chemicals
None of the above

Do you confirm that you will not be performing activities that involve; hot work, tools or equipment over 50 volts, confined space entry, excavation, x-ray or radiation, crane, work at height over 4 feet, line or equipment opening, or performing a lockout/tagout?

Has the contractor checked in with operations and discussed location of equipment and the type of equipment being used along with any abnormal conditions?

Name and signature of person performing work.

Name of company

This does not replace signing in and out in the lobby. You must do both.

Will there be any man-made cut, cavity, trench, or depression in an earth surface, formed by earth removal.

Has the location of all underground utilities been identified?

Work can not continue until underground utilities have been identified or referred to be non-existent.

Will the planned excavation depth exceed 4 feet?

Which of the following methods will be utilized to prevent cave-ins or wall collapse?

Is there adequate room to slope?

A different method is required.

Is a signal man readily available?

Signal man is needed to proceed with this operation.

Rescue plan

Explain evacuation plan.

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.

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

Is a Lockout/Tagout required?

Was a lock box issued?

Enter lock box number

Scan in lockout/tagout log if applicable.

Overhead Work including any of the following (Cranes, manlift, scissor lift, or other personnel at height)

Are barricades in place?

Has FPC management reviewed the lift plan?

Have inspections for crane and all rigging been verified to match paperwork and are they current and stored on file?

Has minimum clearance of 10 feet for 0 - 50 kV powerlines been measured and marked where necessary?

Enter the maximum windspeed forecasted for the duration of the lift.

Wind speed entered is greater than 20 mph and lift should not be performed.

Does the manlift or scissor lift have a current inspection?

Does the manlift/scissor lift operator have up-to-date training?

Do all personnel in the basket have the proper fall protection?

Has minimum clearance of 10 feet for 0 - 50 kV powerlines been measured and marked where necessary?

Does the height affected personnel have the proper fall protection?

Are mechanical devices such as a rope available for lifting tools to minimize dropped object potential?

Has minimum clearance of 10 feet for 0 - 50 kV powerlines been measured and marked where necessary?

Will there be any work involving radio active materials or sources (e.g. X-Ray)

Does the contractor have the appropriate qualifications and training?

Has the contractor pre-tested the exposure dose in order to determine the appropriate stand off radius and direction?

Has yellow and magenta barricade tape been placed to keep personnel from potential overexposure?

Is an atmosphere test required? (required if entering a confined space and/or performing hot work)

LEL%

Enter LEL%

LEL% IS AT AN UNSAFE LEVEL.

O2%

Enter O2%

O2% IS AT AN UNSAFE LEVEL

CO PPM

Enter CO PPM

CO PPM IS AT AN UNSAFE LEVEL.

H2S PPM

Enter H2S PPM

H2S PPM IS AT AN UNSAFE LEVEL

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.

O2 Bottle / Breather Box verified working?

Verify to be working prior to work.

Name of Bottle Watch

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.

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)

An appropriate fire extinguisher should be readily available for any hot work being performed.

Appropriate SDS available

Stop and locate SDS before continuing.

Affected personnel notified

Please notify affected personnel before continuing.

Specify Hazards

List Hazards

Barricade Tape/Safety cones in place

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

Company Performing Work

In House (FPC)
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
Sepratech
Hydrochem
Other

Enter name of contractor

Worker Name & Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name and Signature

Additional Worker

Worker Name and Signature

Additional Worker

Worker Name & Signature

Additional Worker

Worker Name & Signature

Area Certified Personnel Name & Signature

Second Certified Personnel Name & Signature