Shell Retail Permit To Work System_5 1- Forms

RETAIL PERMIT TO WORK SYSTEM – WORK CLEARANCE FORM Tick the applicable Life Saving Rules for this activity

General Information Date:……………….………………………………………………………. Person undertaking work:……………………………………................. Job / Work Order No.:.………………………………………………......... Company:…………………………………………………………………… Site Address:……………………………………………………………… Minimum level of PPE to be worn / used at all times. Tick for confirmation

Work to be done: …………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………............. HIGH RISK ACTIVITY (PERMIT+ Job Hazard Analysis)

MEDIUM RISK ACTIVITY (Job Hazard Analysis)

OTHER

Consult “Appendix 2 - Retail Permit to Work - Activity Table” or your supervisor for more information

Permit No.: ………………..

JHA Reference No.: ………………..

JHA Review No.: ………………..

Hazards and Controls Tools / equipment to be used (e.g. hand tools, mechanical tools, plant etc): ……………………………………................... ……………………………………………………………………………………………………………………………………,………. …………………………………………………………………………………………………………………………………….………. Hazards (e.g moving vehicles, electrocution etc.) and Controls (e.g guardrails, barricading, lockout/tag out, etc). Note: For Medium or High Risk activity refer to the JHA for further details. The Predetermined JHA must be reviewed for the work that will occur EACH DAY that the permit is open. The Permit Holder must ensure that any changes have been Risk Assessed and the Permit and/or associated JHA is updated to reflect changing conditions.

Hazards

Controls

Comments

Personal Protective Equipment (PPE) appropriate to the task: ……………….…………………………………………………………….. ………………………………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………….... Fire extinguisher(s) located at: …………………………………………………………….…………………………………………….. Remember to carry out the Last Minute Risk Assessment before and during any task ACKNOWLEDGEMENT OF WORK – CONTRACTOR The contractor acknowledges that the job will be performed in line with the precautions listed above, that all proposed work has been discussed with the Site Representative, and that the Site Representative will be informed of any incidents Contractor Site supervisor certify that the work crew have a valid Safety Passport and can perform work at a Shell Retail location NAME: SIGNATURE: TIME: DATE: ACKNOWLEDGEMENT OF WORK CREW - The work crew acknowledges that they understand and will comply with the precautions listed above (not required for medium and high risk activities) SIGNATURES

ACKNOWLEDGEMENT OF WORK - SITE REPRESENTATIVE The Site Representative witnesses the Contractor's signature and agrees to inform the Contractor of any change in site conditions such as tanker delivery or delivery of food goods NAME: SIGNATURE: TIME: WORK CLEARANCE CLOSE OUT - CONTRACTOR The contractor acknowledges that the job has been completed / suspended and the site has been left in a safe and satisfactory condition.

DATE:

NAME: SIGNATURE: WORK CLEARANCE CLOSE OUT - SITE REPRESENTATIVE The Site Representative acknowledges that the job has been completed / suspended

TIME:

DATE:

NAME:

TIME:

DATE:

SIGNATURE:

Appendix 4 - Shell Retail Permit to Work _ Version 5.1

RETAIL PERMIT TO WORK SYSTEM – JOB HAZARD ANALYSIS

Date:

Will the work involve any of the activities below? (Circle any that apply) If ‘YES’ a Permit must be obtained

Prepared by: Company: Retail Station Address:

Hot work in Hazardous areas

Confined space entry

Excavation >/= 1.2 m

Inerting or Gas Freeing

Work on Flammable Gas Systems Explosive Blasting

Live Electrical Work

Asbestos Work JHA Reference No.: ___________________________

Other (specify):

JHA Review No.: _____________________________

Predetermined JHA shall be verified and reviewed on site every day before performing the work. Description of work and number of days anticipated : ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________

Step No

Job Step

Job Step Hazard

Job Step Control

Shell Retail Permit to Work _ Version 5.1

RETAIL PERMIT TO WORK SYSTEM – JOB HAZARD ANALYSIS Personal Protective Equipment (PPE) appropriate to the task at hand shall be worn/used at all times. Tick box any PPE that applies to this job

Any additional PPE appropriate to the task :

List required equipment / tools (e.g fire extinguisher, barricading / signs , hand tools, mechanical tools, plant etc.):

The work crew acknowledges that they understand and will comply with the precautions listed above NAME:

SIGNATURE:

NAME:

SIGNATURE:

NAME:

SIGNATURE:

NAME:

SIGNATURE:

NAME:

SIGNATURE:

NAME:

SIGNATURE:

Shell Retail Permit to Work _ Version 5.1

RETAIL PERMIT TO WORK SYSTEM – PERMIT TO WORK A copy of this Permit along with any applicable attachments must be readily available at the work site Site Address:…………………………………………………………………… Site Representative:……………….………………………………………….. Site Phone:……………………………………………………………………... Permit Issuer: Permit Issuer phone: Permit Holder: Permit Holder phone:

…………………………………... …………………………………... …………………………………... …………………………………...

Permit No.:

Permit Validity From (dd/mm/yy): Permit Validity To (dd/mm/yy): Time From: Time To:

……………… …………………………… …………………………… …………………………… ……………………………

The activities below apply to the work ( Tick those activities that apply ) __Hot Work in Hazardous areas __Confined Space Entry __Excavations > / = 1.2 meters __Inerting or Gas Freeing

__Work on Flammable Gas Systems __Live Electrical Work __Asbestos Work

_Explosive Blasting __Other (Specify) ……………………

…………………………………….

Equipment Isolation Responsibility (LOTO) Equipment to be Isolated: Electrical / Mechanical / Fluid

Date

Isolation Established by: Time Printed Name, Signature & Company

Date

Isolation Withdrawn by: Time Printed Name, Signature & Company

Equipment Re-commissioning responsibility / instruction: .......................................................................................... .............................................................................................................................................................................................. .............................................................................................................................................................................................. Emergency Response: Phone Numbers : Fire: ............................................. Police: ……………………………… Ambulance: …………………………

Location of nearest medical facility………………………………………………… Emergency meeting point: ………………………………………………………….. Other:…………………………………………………………………………………..

Additional hazards and controls that are not documented in the WCF and in the JHA : …………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………………... …………………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………………….. Other documents and attachments applicable to this Permit are (e.g JHA, gas testing records, legal permits etc.): ……………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………… Signature

Company

Date

Time

Permit acceptance by Permit Holder:

……………………

……………………

……………………

…………………

Permit authorised by Permit Issuer:

……………………

……………………

……………………

…………………

Permit close out by Permit Holder:

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……………………

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Permit close out by Permit Issuer :

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Appendix 5 - Shell Retail Permit to Work _ Version 5.1