1. Confined Space Work Permit
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. (MUST BE CHIEF OPERATOR)
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
Blinds Verified & Blind-List initialed
Safety Department Notified Y
Blinded/Disconnected
Lock Box Number:
Rescue Services Available
Equipment Opened/Depressurized
External Atmosphere
Trained Entry Attendant
Valves-Closed/Tagged/Chained/Locked
Aspirating / Fans / Air Flow
Orange Vest
De-energized Electrical Systems
Grounded / Bonded
Signal Horn
Electrically Locked/Tagged out
Main Air supply Valves Tagged
Radio CH________________
Field Test / Attempt to Energize-start
Natural Draft
Sign-in/sign Out Log
Vessel Decontamination
Radioactive Sources Secure
Retrieval System
Water Washed
120V Electrical equip GFCI
Life Line
N2 Purged
Low Voltage Lighting (12V)
Continuous air Monitor
Steamed
Inert Entry Procedure (SSP-0015)
Bottle Watch
Othe
Confined space Signs Posted
Additional Standby
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 Confined Space 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
Test 3
Test 4
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 End
Authorized Start
Print Name
Signature
Date
Permit Holder
Permit Issuer (Chief Operator)
Unit Operator
Shift Supervisor
Confined Space Attendant
All Signatures are Required
PRIOR to EXTENDING
permit up to 12 hours
Time Start
Time End
Authorized Continue
Print Name
Signature
Date
Permit Holder
Permit Issuer (Chief Operator)
Unit Operator
Shift Supervisor
Confined Space Attendant
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. Permit Number will be pre-printed on form
For office use -- This area is for the Required OSHA permit Review process and is completed later.
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.
Must be the Chief Operator
Indicate product last in vessel so proper PPE can be assessed..
<< Indicate if the MSDS was checked for the previous product in the vessel – then make any relevant comments in this area.
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
If radios are provided note radio and channel
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:
Based on the work and hazards – specific required PPE should be Identified for the permitted work.
Identify any additional or specific Hazards of explanations of certain above information.
If HF Alky involved indicate PPE Level
Clarify additional controls or special instructions for the work..
These names, signatures and date must be complete and the Start and End time for the permit set (above) prior to work start.
A Meraux employee (or designated contractor during turnaround events) who is qualified to do air testing must test the work area prior any confined space work and must take additional samples during the course of the work. A separate form for tracking confined space entry and other required will also be required.
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, date and time on the form.
If HF Exposure– indicate and
Ensure area Cleaned.