1. All Signatures are Required PRIOR to INITIAL confined space entry. Authorized Entry Print NameSignatureDate Permit Holder Permit Issuer Shift Supervisor Confined Space Attendant Job Hazards Y Standard Controls Job Hazards Y Standard Controls PPE Req’d Access & EgressHousekeeping, Walkways, StairsManual HandlingAssessment,& Equipment Standard (SSP-0011) Y Activities-Proximity of OthersCommunications, Barriers, PermitMoving PartsCovers, Isolation, & Maintenance Full Face Shield Adverse WeatherStop Work & Take RefugeNoiseInsulation, Hearing Protection, & PPE Goggles Chemical ExposureMSDS Review, PPEOverhead CablesLabelling, Isolation, & Barriers Hearing Protection Vehicle EntryProcedures, Barriers, & PermitSharp EdgesCovers, PPE, & Equipment Inspections Fall Protection Y 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, PPEInside Falling MaterialScaling walls, shoring up, securing Inside TemperatureCheck Temp, Ventilation, A/C Meraux Refinery Confined Space 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. (Must be Chief Operator) 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 Followed Y Lock Box Number:Safety Department Notified Y Blinded/DisconnectedAspirating / Fans / Air FlowRescue Services Available Y Equipment Opened/Depressurized Grounded / BondedTrained Entry Attendant Y Valves-Closed/Tagged/Chained/Locked Main Air Supply Valves Tagged Evacuation Horn Y Electrically locked / tagged out Natural Draft Orange Vest Y Field Test / Attempt to Energize-startRadioactive Source Secure Sign in/Sign out log Y Blinds Verified & Blind-List initialed Y Internal Lighting Contact: Vessel Decontamination Low Volt 12 V lights Retrieval System Water Washed 120 V w/ GFCI Life Line N2 Purged Inert Entry Procedure Continuous air monitor Steamed Confined Space Signs Posted Y Bottle Watch / Additional Standby NoDateTime%LELOxygenH2SH2SCOOtherSerial NoMeraux Qualified Person: 1 2 3 4 Permit End Work Completed Work Site in Safe ConditionPrint NameSignatureDate CSE Permit Review Within 12 months Permit Holder  Yes  No By: Unit Operator  Yes  No Date: 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. 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 Shift Supervisor Confined Space Attendant