1. SAFE Work Permit  Meraux Refinery  Cold Work Low Energy
Permit Number:
Permit Review
By:
Date:
Information to be completed by Permit Requestor/Holder
Company:
 Meraux Refinery
Contractor Name 
Area/Unit
Permit Holder:
Tools/Equipment to be used:
Equipment #
# Persons: Work Order #:
Hand tools
Lift trucks
Double Insulated Electric
Other:
Scope of Proposed Task:
Please initial that the Scope of work is clear and understood. Permit Holder: Permit issuer:
Information to be completed by Permit Issuer.
Previous Product
in Equipment:
MSDS Checked
Yes
N/A
Additional
PPE Required?
Equipment Pre-Work
Req’d
Done
Area Preparation
LOTO Procedures Followed
Y -- N
Lock Box Number:
Bottle Watch
Blinded/Disconnected
Decontamination
Additional Standby
Equipment Opened/Depressurized
Water Washed
Low energy work Preparation
Valves-Closed/Tagged/Chained/Locked
N2 Purged
120V Electrical equip GFCI
De-energized Electrical Systems
Steamed
Prepared for Vehicle Entry
Electrically Locked-out/Tagged Out
Other
Sumps-drains covered
Field Test / Attempt to Energize-start
Radioactive Sources Secure
Electrical Connections Taped
Blinds Verified & Blind-List initialed
Vehicle Wheels Chocked
Job Hazards Y
Standard Controls
PPE
Req’d
Static Electricity
Grounding,
Manual Handling / Lifting
Assessment & lifting equipment
Standard (SSP-0011)
Y -- N
Slips, Trips & Falls
Housekeeping, & PPE
Moving Parts
Covers, Isolation, & Maintenance
Full Face Shield
Chemical /Fuel Exposure
MSDS Review, PPE
Overhead Hazards
Labelling, Isolation, & Barriers
Goggles
Vehicle Entry in the unit?
Procedures, Barriers, & Permit
Sharp Edges
Covers, PPE, & Equipment Inspections
Hearing Protection
Electricity
Isolation, LOTO, GFCI
Activities of Others
Communications, Barriers, Permit
Fall Protection
Flammable Vapors / liquid
Gas Testing & Isolation
Access & Egress
Housekeeping, Walkways, Stairs
Leather Gloves
Fumes & Dust
Respirator / Eye Protection
Trapped Pressure
Venting, Draining, & PPE
Rubber Gloves
Hot Surfaces
Insulation / Barriers / PPE
Vehicle Traffic
Hi-Vis Clothing, Speed Limit, & Signs
Non Permeable Suit
Toxic Vapors / Liquids
Underground Hazards
CAT Testing, Labelling, & Barriers
Respirator ½ face
Excavation
Excavation Checklist
Hot Liquid
Procedures & PPE
Respirator Full Face
Weather Extremes
Schedule, breaks.
Working at Height
Scaffolding & Fall Protection / Harness
Filter Type:
Spillage to Ground
Secondary Containment
Working Over Water
Life Jacket, & Safety Boat,
Supplied Air
Spillage to Water
Containment / Booms
Mechanical Lifting
Barriers / Lift Procedures
Personal H2S monitor
HF Alky -- LEVEL “A”:
Totally encapsulated suit – positive pressure
HF Alky -- LEVEL “B”:
One piece coverall, gloves w/sealed cuffs, HF boots, positive flow hood w/ air line.
HF Alky -- LEVEL “C”:
One Piece Coverall, HF Boots, Gloves w/sealed Cuffs/ face shield
Specific Hazards:
Additional Controls and/or Special Instructions:
Signing this Work Permit signifies the job site has been inspected by the Permit Issuer and Permit Requester/Holder, the area is prepared, and each individual has agreed to comply with the conditions of this permit.
The Permit is valid through the end of the current work shift (start and end times below) and may be extended into the next shift if necessary.
Test 1
Test 2
Date
Time
Oxygen
LEL
H2S CO
Benzene
Other
Serial #
Calibrated?
Initial -- Meraux Qualified Person
All Signatures are Required
PRIOR to INITIAL work.
Time Start
Time Expires
Authorized Continue
Print Name
Signature
Date
Permit Holder
Permit Issuer
Chief Operator (if required)
All Signatures are Required
PRIOR to EXTENDING
Permit into the following shift.
Time Start
Time Expires
Authorized Continue
Print Name
Signature
Date
Permit Holder
Permit Issuer
Chief Operator (if required)
Permit End
Work Complete
Safe/Clean Job-Site?
Exposed
HF Acid
HF PPE
Cleaned?
Print Name
Signature
Date
Time
Permit Holder
Y N
Y  N
Unit Operator

2. Please designate if this is “Cold Work” or if Low Energy which includes only Vehicular Entry into a unit or low voltage only work.
Please see hot work permit instructions
Check if Meraux personnel doing work
Check and indicate Contractor Name for contractor work
The Permit Holder completes this section of the permit prior to meeting wit permit issuer.
Person responsible for directly supervising the work.
How many will be involved performing work
Indicate work order numbers
List tools & equipment to be used.
The Permit Holder should describe the scope of work to be completed in this area.
Permit Issuer is an operator for the area involved
<< Indicate if the MSDS was checked for the previous product in the vessel and any additional PPE required.
Indicate product last in vessel so proper PPE can be assessed..
The permit issuer and Permit Holder also ensure area preparation is required and Done for Bottle Watch or Low Energy Work.
The Permit Issuer and Permit Holder work through this section to ensure that:
1 – all Equipment Pre-Work area are checked to indicate what is REQUIRED (Req’d)
2 – to ensure that all REQUIRED Pre-Work is actually DONE
Based on the work and hazards – specific required PPE should be Identified for the permitted work.
The Permit Issuer and Permit Holder also inspect the area for Job Hazards. In this area if a Job Hazard exists the box should be checked. Standard Controls or other appropriate measures should be taken to ensure the area is safe for work.
Also – potential Environmental impacts are noted below:
If HF Alky involved indicate PPE Level
Identify any additional or specific Hazards of explanations of certain above information.
Clarify additional controls or special instructions for the work..
A Meraux employee (or designated contractor during turnaround events) who is qualified to do air testing must test the work area prior to any Vehicle entry or other low energy work being performed for this permit. These readings are noted here. A signature is required
These names, signatures and date must be complete and the Start and End time for the permit set (above) prior to work start.
If, at the end of the shift, it is necessary to extend the permit, the on-coming Permit Holder and Issuer must review the area to ensure conditions have not changed and re sign the permit with start and end times.
When the work is complete the Permit Holder and the Unit Operator should review the work and indicate whether it is complete and the site is in Safe condition – then print and sign their name and date the form.
If HF Exposure– indicate and
Ensure area Cleaned.