1. All Signatures are Required PRIOR to INITIAL work. Authorized Entry Print NameSignatureDate Permit Holder Permit Issuer Chief Operator (if required) Job Hazards Y Standard Controls Job Hazards Y Standard Controls PPE Req’d Access & EgressHousekeeping, Walkways, StairsManual HandlingAssessment,& Equipment Standard (SSP-0011) Y Activities of OthersCommunications, Barriers, PermitMoving PartsCovers, Isolation, & Maintenance Full Face Shield Adverse WeatherStop Work & Take RefugeNoiseInsulation, Hearing Protection, & PPE Goggles Chemical /Fuel ExposureMSDS Review, PPEOverhead CablesLabelling, Isolation, & Barriers Hearing Protection Vehicle EntryProcedures, Barriers, & PermitSharp EdgesCovers, PPE, & Equipment Inspections Fall Protection ElectricityIsolation, LOTOSlips, Trips & FallsHousekeeping, & PPE Chemical Gloves Exposure to FuelsPPEStatic ElectricityGrounding, Chemical Suit FatigueRest Periods, RefreshmentsTrapped PressureVenting, Draining, & PPE Respirator ½ face Fire & ExplosionGas Testing & IsolationVehicle TrafficHi-Vis Clothing, Speed Limit, & Signs Respirator Full Face Fumes & DustFilter Mask, Eye ProtectionUnderground CablesCAT Testing, Labelling, & Barriers Air Supplied Hood/Line Soil/Water ContaminationIsolationHot LiquidProcedures & PPE SCBA Secondary ContainmentProceduresWorking at HeightHand Rails, Harness, & Life-Line Personal H2S monitor Y Hot SurfacesProcedures & PPEWorking Over WaterLife Jacket, & Safety Boat,Other.. Nature (insects, snakes…)Awareness, Remove, PPE Meraux Refinery Work Permit Permit Number: Information to be completed by Permit HolderCompany:  Meraux Refinery Contractor Name  Area/UnitPermit Holder:Date: Equipment ## Persons: Work Order # (s) Scope of Proposed Task: Information to be completed by Permit Issuer. Work Description: Previous Product in Vessel: MSDS Checked  Yes  No Comment: Equipment Pre-Work Req’d Done Equipment Pre-Work Req’dDone Area Preparation Req’dDone LOTO Procedures FollowedLock Box Number:Bottle Watch Blinded/DisconnectedBlinds Verified & Blind-List initialed Equipment Opened/DepressurizedDecontamination Low energy work Preparation Valves-Closed/Tagged/Chained/Locked Water Washed Lighting 120 V w/ GFCI Electrical Systems N2 Purged Prepared for Vehicle Entry Field Test / Attempt to Energize-start Steamed Sumps-drains covered Blinds Verified & Blind-List initialed Electrical Connections Taped Air testing is required for low energy – non- Hot Work permitted activity. If test are taken, Chief Operator must be notified. NoDateTime%LELOxygenH2SH2SCOOtherSerial NoMeraux Qualified Person: 1 2 Additional Controls Required:Special Instructions: All Signatures are Required PRIOR to EXTENDING permit up to 12 hours. Authorized Entry Print NameSignatureDate Permit Holder Permit Issuer Chief Operator (if required) Permit End Work Completed Work Site in Safe ConditionPrint NameSignatureDate Permit Holder  Yes  No Unit Operator  Yes  No Signing this Work Permit signifies the job site has been inspected by the Permit Issuer and Permit Holder, the area is prepared, and each individual has agreed to comply with the conditions of this confined space permit. The Permit is valid for a period of up to 12 hours or may be extended (below) for up to 24 hours.