ROUTINE MAINTENANCE SAFE WORK PERMIT (SHELL)

(See Condition of Use on Reverse)

Date: W/O No: Description of Planned Work: Site No: Prime Contractor: Completed By:

Note: Record any significant unusual or unexpected e ents on re erse!

Su"contractor#s$:

SECTION A: HAZARD IDENTIFICATION AND CONTROL W%ere t%e follo&ing ele ated risk site %a.ards exist+ '0e 5SA on t%e re erse must "e completed:
O er%ead Po&er 'ines ,raffic -a.ardous /aterial #)uel+ 0s"estos+ ,oxic C%emical+ )reon+ etc!$ 1nclement Weat%er #specify$: /o"ile -ea y (2uipment 0cti ity #Boom ,ruck+ Scissor 'ift$ Welding+ Cutting+ *rinding in non4%a.ardous atmosp%ere (xca ation less t%an 5!6m Potential (nergy #)luid or *as under Pressure+ (lectricity$ Slip/,rip Ot%er #specify$:

W%ere t%e follo&ing ele ated risk &ork %a.ards exist+ '0e 5SA on t%e re erse must "e completed:
)uel Pressure/3acuum ,esting Coordination 1nterdependency #O erlapping ,rades$ Ot%er #specify$:

W%ere t%e follo&ing %ig% risk &ork %a.ards exist+ t%e applica"le critical task c%ecklist or procedure must "e completed and incorporated into '0e 5SA on t%e re erse
Work at -eig%t a"o e 7!6m Confined Space (ntry #S,P Sump+ Car Was% Sump+ etc!$ 'ock Out/,ag Out (2uipment 1solation Re2uired 8se of 3acuum ,ruck Cutting+ *rinding in %a.ardous atmosp%ere Critical Controls affected #'eak Detection+ 3ideo 'oss+ etc!$ -ea y (2uipment 'ifting #i!e!+ &it% Crane or Boom ,ruck$ Ot%er #specify$:

SECTION B: CONFIRMATION OF BASIC REQUIREMENTS

Work &ill "e conducted in accordance &it% applica"le O-9S regulations and Prime Contractor:s Safety Policy! W-/1S Re2uirements are met+ if applica"le! 0ppropriate Personal Protecti e (2uipment &ill "e used "y Workers and 3isitors in Work 0rea! Certified appropriate )ire (xtinguis%er#s$ are a aila"le in Work 0rea+ if applica"le! ,ools and (2uipment to "e used are appropriate and in good &orking Condition! 0ll &orkers are ade2uately trained for t%eir ,asks!

T!!) 4E6uip"e$' '! .e u e( '0#' #re Re)ev#$' '! S#&e'% 'Ladder, (arricades, Tri)od, %arness, *orta$le +as Monitor, etc&,:

A((i'i!$#) PPE Re6uire"e$' 7 i& A$% 'at Minimum: Safety (oots#%ard %at#-isi.-est#Safety +lasses#+lo/es Fit for 0se,:
Ot%er (ye Protection #specify$: -earing Protection Ot%er #Specify$: )all Protection Breat%ing 0paratus/Dust /ask

SECTION C: LAST MINUTE RISK ASSESSMENT (LMRA) TESTIN- RESULTS '*eriodic,

Supervi !r C!"p#$% N#"e Cr#&' !r Tr#(e Te ' Re u)' (N!* !u' !& +) Supervi !r Si,$#'ure

***Four criteria for testing LRMA quality: understands task, risk identification, adequate risk mitigation and attitude

SECTION D: ACKNOWLED-EMENTS OF PLANNED WORK

Name: Re p!$ i.)e Te/0 1 Re p!$ i.)e Te/0 2 Re p!$ i.)e Te/0 3 Person completing ,%is Permit #Named 0"o e$ Signature:

RETAILER4SALES ASSOCIATE:
Signature

am/pm Work Start Time

am/pm Signature Finis Time

N!T": T e Retailer#SA Assumes No Lia$ility for t e %ealt and Safety of t e Workers&

CONDITION OF USE: THIS FORM IS APPLICABLE DAIL8 FOR ALL RETAIL MAINTENANCE WORK E9CEPT FOR THE FOLLOWINSITUATIONS7 IN WHICH CASE A POST SAFE WORK PERMIT FORM MUST BE USED: 4 /ore t%an ; tec%nicians/trades at one time+ up to a maximum 6 &orkers at one time including %elpers+ or 4 Work expected to re2uire more t%an < days to complete+ or 4 Work &it%in a fenced area+ or 4 -ig% Risk Work #demolition+ exca ation greater t%an 5!6m+ confined space entry except S,P sumps+ open flame in %a.ardous area+ erection of structures$!

5OB SAFET8 ANAL8SIS (5SA)

H#:#r(!u A/'ivi'% '!rder in 1 ic t e 1ork 1ill $e carried out and $rief details of o1 tasks 1ill $e )erformed,& P!'e$'i#) H#:#r( '"2am)les: electric s ock, fall, fire, cut, /e icle im)act, c emical s)las , as) y2iation, critical control $y)assed, etc&, S#&e'% C!$'r!) '! Re(u/e !r E)i"i$#'e H#:#r( '3escri$e t e )recautions t at 1ill $e taken,

7 < ; = 6 > ? @
Si,$i&i/#$' u$u u#) !r u$e;pe/'e( eve$' e$/!u$'ere( (uri$, <!r=7 i& #$%:

ROUTINE MAINTENANCE SAFE WORK PERMIT

(See Condition of Use on Reverse)
Date: W/O No: Description of Planned Work: Su"contractor#s$: Site No: Prime Contractor: Completed By:

Note: Record any significant unusual or unexpected e ents on re erse!

SECTION A: HAZARD IDENTIFICATION AND CONTROL W%ere t%e follo&ing ele ated risk site %a.ards exist+ '0e 5SA on t%e re erse must "e completed:
O er%ead Po&er 'ines ,raffic -a.ardous /aterial #)uel+ 0s"estos+ ,oxic C%emical+ )reon+ etc!$ 1nclement Weat%er #specify$: Potential (nergy #)luid or *as under Pressure+ (lectricity$ Slip/,rip Ot%er #specify$:

W%ere t%e follo&ing ele ated risk &ork %a.ards exist+ '0e 5SA on t%e re erse must "e completed:
/o"ile -ea y (2uipment 0cti ity #Boom ,ruck+ Scissor 'ift$ Welding+ Cutting+ *rinding in non4%a.ardous atmosp%ere (xca ation less t%an 5!6m )uel Pressure/3acuum ,esting Coordination 1nterdependency #O erlapping ,rades$ Ot%er #specify$:

W%ere t%e follo&ing %ig% risk &ork %a.ards exist+ t%e applica"le critical task c%ecklist or procedure must "e completed and incorporated into '0e 5SA on t%e re erse
Work at -eig%t a"o e 7!6m Confined Space (ntry #S,P Sump+ Car Was% Sump+ etc!$ 'ock Out/,ag Out (2uipment 1solation Re2uired 8se of 3acuum ,ruck Cutting+ *rinding in %a.ardous atmosp%ere Critical Controls affected #'eak Detection+ 3ideo 'oss+ etc!$ -ea y (2uipment 'ifting #i!e!+ &it% Crane or Boom ,ruck$ Ot%er #specify$:

SECTION B: CONFIRMATION OF BASIC REQUIREMENTS

Work &ill "e conducted in accordance &it% applica"le O-9S regulations and Prime Contractor:s Safety Policy! W-/1S Re2uirements are met+ if applica"le! 0ppropriate Personal Protecti e (2uipment &ill "e used "y Workers and 3isitors in Work 0rea! Certified appropriate )ire (xtinguis%er#s$ are a aila"le in Work 0rea+ if applica"le! ,ools and (2uipment to "e used are appropriate and in good &orking Condition! 0ll &orkers are ade2uately trained for t%eir ,asks!

T!!) 4E6uip"e$' '! .e u e( '0#' #re Re)ev#$' '! S#&e'% 'Ladder, (arricades, Tri)od, %arness, *orta$le +as Monitor, etc&,: A((i'i!$#) PPE Re6uire"e$' 7 i& A$% 'at Minimum: Safety (oots#%ard %at#-isi.-est#Safety +lasses#+lo/es Fit for 0se,:
Ot%er (ye Protection #specify$: -earing Protection Ot%er #Specify$: )all Protection Breat%ing 0paratus/Dust /ask

SECTION C: LAST MINUTE RISK ASSESSMENT (LMRA) TESTIN- RESULTS '*eriodic,

Supervi !r C!"p#$% N#"e Cr#&' !r Tr#(e Te ' Re u)' (N!* !u' !& +) Supervi !r Si,$#'ure

***Four criteria for testing LRMA quality: understands task, risk identification, adequate risk mitigation and attitude

SECTION D: ACKNOWLED-EMENTS OF PLANNED WORK

Name: Re p!$ i.)e Te/0 1 Re p!$ i.)e Te/0 2 Re p!$ i.)e Te/0 3 Person completing ,%is Permit #Named 0"o e$ Signature:

RETAILER4SALES ASSOCIATE:
Signature N!T": T e Retailer#SA Assumes No Lia$ility for t e %ealt and Safety of t e Workers&

am/pm Work Start Time Signature Finis Time

am/pm