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This permit to work is the formal way of tracking the authorization and communication of all non-standard work activities
Date of Work Activity: Time of Work Activity: Expires on:

Section 1: Work Request Information

Description of Work and Area:

Section 2: Work Planning

Will production need to be interrupted? Coordinated with affected employees? Team members have adequate training?

Yes No n/a Yes No n/a Yes No n/a

Is there a risk of falling 4' or more? Is the work outdoors? Other concerns?

Yes No n/a Yes No n/a

SDS/Manual Evacuation Bright/Heat

PPE Safety Needs Other Safety Equipment Needs? No

Heat resistant Hardhat (class E) Harness

Cut resistant Respirator Hearing

Weld screen Insulated tools
Chemical resistant Face shield Restraint

Long Sleeves Hi-Vis vest Apron

Steel / Composite toe Welding shield Cold gear

Safety net Roof flags Eye/Shower
Safety glasses Fire retardent Rain gear

Energized Electrical Work? Y N Hot Work? Y N Permited Confined Space Entry? Y N

1. Does the work area have adequate
1. Is LOTO necessary and performed? 1. Is LOTO necessary and performed?
2. Equipment being worked made safe for
2. Are the boundaries established? 2. Is ventilation necessary and utilized?
3. Does Electrician have / using
appropriate PPE and tools? 3. Are Blinds installed? 3. Is personnel properly trained?

4. Is a fan available to move air

4. Is Electrician trained in Arc Flash safety? contaminants? 4. Is rescue equipment available?

5. Is a medically trained responder 5. All flammables atleast 35' away from 5. Is communications available?
available and notified of work? work?
6. Work is justified because de-energizing 6. All combustibles and holes (floor, sewer)
and locking out: Y N covered? 6. Is multi-gas meter charged / calibrated?

Involves additional hazards? 7. Is a 30-minute fire watch required? X 7. Is O2 %'age >19.5% & <23.5%?

Introduces increased hazards? 8. Does welder / fire watch have 8. Is CO < 35-ppm?
appropriate PPE?

Is infeasible due to equipment design? 9. Is fire watch trained in fire extinguisher 9. Is H2S < 10-ppm and LEL < 10%?

Other Justification: 10. Sprinkler system operational? 10. Is periodic air monitoring
Safe Statement (All other notes regarding safe work preparation):

Section 3: Mandatory Approvals

Permit Requester Supervisor / Manager
I have communicated these requirements and expectations above to all I confirm the Permit Requester has properly communicated the requirements
personnel involved in the work and accept full responsibility for the work and and expectations to all personnel involved in the work and authorize the work to
safety of all personnel involved and performing the work. be safely carried out.

Print Name: Print Name:

Signature: Signature:

Phone: Phone:

Date: Date:

Uncontrolled when printed EOH-SP-FORM-531.01 Issued: 11/18/20

Permit To Work
Code: D-SP-FORM-531.01 Page 1 of 1 Author: EHS
Issued: 5/31/2019   Approved: EHS
Revised: 5/31/2019 Rev #: 000 Status: Uncontrolled when Printed
Person(s) Conducting Hot Work: Hot Work Type: Type of Welder (If Appliciable):

Designated Fire Watch: Minimum Hot Work Watch Time: Work Order Number:
30 Mins 60 Mins Other____________

Section 1: Checklist

  Has LOTO been performed on the equipment/piping? YES NO N/A Notes:

Have blinds been installed, if necessary? YES NO N/A Notes:

Has equipment been cleaned, purged, steamed or made safe for welding? YES NO N/A Notes:

Is it permissible to use electric tools or gasoline driven equipment? YES NO N/A Notes:

Have sewers been covered for a radius of 35 feet? YES NO N/A Notes:

Is a 30 minute firewatch required? YES NO N/A Notes:

Has firewatch person been fire extinguisher trained? YES NO N/A Notes:

   Is it necessary to cover working platform with fire blanket? YES NO N/A Notes:

Is an air mover needed to remove air contaminants? YES NO N/A Notes:

Have cracks / holes been identified where sparks can fall on combustibles? YES NO N/A Notes:

Is it necessary to prevent fires in ceilings, floors, walls, partitions or roofs of combustible

YES NO N/A Notes:
Are precautions necessary to protect against heat conduction to combustible materials
YES NO N/A Notes:
including sandwich construction?
Does the welder and firewatch have appropriate PPE? YES NO N/A Notes:

  Is fire extinguishing equipment available for immediate use? YES NO N/A Notes:

  Is the sprinkler protection system operational in the work area? YES NO N/A Notes:

Is respiratory protection required? If so, what type? YES NO N/A Notes: