ROUTINE MAINTENANCE SAFE WORK PERMIT (SHELL)(See Condition of Use on Reverse)

Date: Site No: Completed By:

W/O No: Prime Contractor:Description of Planned Work:

Note: Record any significant unusual or unexpected events on reverse.

Subcontractor(s):

SECTION A: HAZARD IDENTIFICATION AND CONTROL

Overhead Power Lines Potential Energy (Fluid or Gas under Pressure, Electricity)Traffic Slip/TripHazardous Material (Fuel, Asbestos, Toxic Chemical, Freon, etc.) Other (specify):Inclement Weather (specify):

Mobile Heavy Equipment Activity (Boom Truck, Scissor Lift) Fuel Pressure/Vacuum TestingWelding, Cutting, Grinding in non-hazardous atmosphere Coordination Interdependency (Overlapping Trades)Excavation less than 0.5m Other (specify):

Work at Height above 1.5m Cutting, Grinding in hazardous atmosphereConfined Space Entry (STP Sump, Car Wash Sump, etc.) Critical Controls affected (Leak Detection, Video Loss, etc.)Lock Out/Tag Out Equipment Isolation RequiredUse of Vacuum Truck Other (specify):

SECTION B: CONFIRMATION OF BASIC REQUIREMENTSWork will be conducted in accordance with applicable OH&S regulations and Prime Contractor's Safety Policy.WHMIS Requirements are met, if applicable.Appropriate Personal Protective Equipment will be used by Workers and Visitors in Work Area.Certified appropriate Fire Extinguisher(s) are available in Work Area, if applicable.Tools and Equipment to be used are appropriate and in good working Condition.All workers are adequately trained for their Tasks.

Other Eye Protection (specify): Fall ProtectionHearing ProtectionOther (Specify):

Supervisor Company Name Craft or Trade Test Results (No. out of 4) Supervisor Signature

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

SECTION D: ACKNOWLEDGEMENTS OF PLANNED WORKName: Signature:

Responsible Tech 1 Person completing This Permit (Named Above)

Responsible Tech 2

Responsible Tech 3

RETAILER/SALES ASSOCIATE: am/pm am/pm Signature Work Start Time Signature Finish Time

NOTE: The Retailer/SA Assumes No Liability for the Health and Safety of the Workers.

Where the following elevated risk site hazards exist, the JSA on the reverse must be completed:

Where the following elevated risk work hazards exist, the JSA on the reverse must be completed:

Where the following high risk work hazards exist, the applicable critical task checklist or procedure must be completed and incorporated into the JSA on the reverse

Heavy Equipment Lifting (i.e., with Crane or Boom Truck)

Tools/Equipment to be used that are Relevant to Safety (Ladder, Barricades, Tripod, Harness, Portable Gas Monitor, etc.):

Additional PPE Requirements, if Any (at Minimum: Safety Boots/Hard Hat/Visi-Vest/Safety Glasses/Gloves Fit for Use):

Breathing Aparatus/Dust Mask

SECTION C: LAST MINUTE RISK ASSESSMENT (LMRA) TESTING RESULTS (Periodic)

CONDITION OF USE: THIS FORM IS APPLICABLE DAILY FOR ALL RETAIL MAINTENANCE WORK EXCEPT FOR THE FOLLOWING SITUATIONS, IN WHICH CASE A POST SAFE WORK PERMIT FORM MUST BE USED: - More than 3 technicians/trades at one time, up to a maximum 5 workers at one time including helpers, or - Work expected to require more than 2 days to complete, or - Work within a fenced area, or - High Risk Work (demolition, excavation greater than 0.5m, confined space entry except STP sumps, open flame in hazardous area, erection of structures).

JOB SAFETY ANALYSIS (JSA)

Hazardous Activity Potential Hazards Safety Controls to Reduce or Eliminate Hazard

(Order in which the work will (Examples: electric shock, fall, fire, (Describe the precautions that will be taken)be carried out and brief details of how cut, vehicle impact, chemical splash,

tasks will be performed). asphyxiation, critical control bypassed, etc.)

1

2

3

4

5

6

7

8

Significant unusual or unexpected events encountered during work, if any:

ROUTINE MAINTENANCE SAFE WORK PERMIT (See Condition of Use on Reverse)

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

Note: Record any significant unusual or unexpected events on reverse.

Subcontractor(s):

SECTION A: HAZARD IDENTIFICATION AND CONTROL

Overhead Power Lines Potential Energy (Fluid or Gas under Pressure, Electricity)Traffic Slip/TripHazardous Material (Fuel, Asbestos, Toxic Chemical, Freon, etc.) Other (specify):Inclement Weather (specify):

Mobile Heavy Equipment Activity (Boom Truck, Scissor Lift) Fuel Pressure/Vacuum TestingWelding, Cutting, Grinding in non-hazardous atmosphere Coordination Interdependency (Overlapping Trades)Excavation less than 0.5m Other (specify):

Work at Height above 1.5m Cutting, Grinding in hazardous atmosphereConfined Space Entry (STP Sump, Car Wash Sump, etc.) Critical Controls affected (Leak Detection, Video Loss, etc.)Lock Out/Tag Out Equipment Isolation RequiredUse of Vacuum Truck Other (specify):

SECTION B: CONFIRMATION OF BASIC REQUIREMENTS

Work will be conducted in accordance with applicable OH&S regulations and Prime Contractor's Safety Policy.WHMIS Requirements are met, if applicable.Appropriate Personal Protective Equipment will be used by Workers and Visitors in Work Area.Certified appropriate Fire Extinguisher(s) are available in Work Area, if applicable.Tools and Equipment to be used are appropriate and in good working Condition.All workers are adequately trained for their Tasks.

Other Eye Protection (specify): Fall ProtectionHearing ProtectionOther (Specify):

Supervisor Company Name Craft or Trade Test Results (No. out of 4) Supervisor Signature

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

SECTION D: ACKNOWLEDGEMENTS OF PLANNED WORKName: Signature:

Responsible Tech 1 Person completing This Permit (Named Above)Responsible Tech 2Responsible Tech 3

RETAILER/SALES ASSOCIATE: am/pm am/pm Signature Work Start Time Signature Finish Time

NOTE: The Retailer/SA Assumes No Liability for the Health and Safety of the Workers.

Where the following elevated risk site hazards exist, the JSA on the reverse must be completed:

Where the following elevated risk work hazards exist, the JSA on the reverse must be completed:

Where the following high risk work hazards exist, the applicable critical task checklist or procedure must be completed and incorporated into the JSA on the reverse

Heavy Equipment Lifting (i.e., with Crane or Boom Truck)

Tools/Equipment to be used that are Relevant to Safety (Ladder, Barricades, Tripod, Harness, Portable Gas Monitor, etc.):

Additional PPE Requirements, if Any (at Minimum: Safety Boots/Hard Hat/Visi-Vest/Safety Glasses/Gloves Fit for Use):

Breathing Aparatus/Dust Mask

SECTION C: LAST MINUTE RISK ASSESSMENT (LMRA) TESTING RESULTS (Periodic)

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