Ergon Safe Work Permit
Permits to work are a formal management system used to control high-risk activities as part of the control safety measures. These enable an assessment of risks to be made and to specify control measures which will be put in place in order to minimize the risk
Ergon - Manor
12/14/2023
Ergon Safe Work Permit
Work Permits to work are a formal management system used to control high-risk activities as part of the control safety measures. These enable an assessment of risks to be made and to specify control measures which will be put in place in order to minimize the risk
Date Issued:
Start Time
End Time
Issued to:
Any employee may cancel this permit any time they consider it necessary. The hard copy of this permit must be available at the job site. Safe work permits and associated documentation must be retained in the facility filing system at H-53-2 for one (1) year.
Type(s) of Work
Description of Work:
Specific Location of Work to Be Performed:
Section I - General Safe Work
1. Job Specific Hazards
2. PPE/Special Equipment Needed
Standard PPE includes hard hat, safety glasses with side shields, 100% cotton clothing, and leather, safety-toed footwear with defined heel. Select the additional equipment needed:
3. The person receiving the permit will verify that all employees:
Have completed visitor/contractor orientation
Understand the job scope and hazards
Understand the housekeeping requirements
Understand the environmental requirements and impacts
Have inspected all tools & equipment
Have inspected and tagged scaffolding safe for use
White Tag (Danger, Do Not Use)
Yellow Tag (Fall Protection Required)
Green Tag (No Fall Protection Required)
4. Potentially affected employees and workers notified of work to be done
5. For demolition or renovation jobs, has EHS been contacted for asbestos and lead paint determination(s)?
Section II - Equipment Preparation (Check all that apply)
Equipment Preparation (Check all that apply)
Section III - Hot Work
Type of Hot Work
Within 35 feet,
1. Are drains, sewers, and basins protected?
2. Are ducts and conveyor systems that could carry sparks to distant combustibles suitably protected or shutdown?
3. Is site free and clean of flammable and combustible materials?
4. Are fire blankets, covers, guards, or metal shields necessary and in place?
5. Are flanges/valves free from leaks and properly covered if needed?
6. Are the floor and ground properly protected?
7. Work on other side of wall?
8. Is trained fire watch necessary and assigned?
Name
Signature
Click here to sign
Relief Name__
Signature
Click here to sign
Section IV - Atmospheric Testing for Hot Work
Not Applicable
Gas Meter ID
Calibration Date
Tester's Initials
Initial Results am/pm
Results _ am/pm
Results _ _ am/pm
Results ______am/pm
Oxygen (20.8 or 20.9%)
Initial Results am/pm
Results _ am/pm
Results _ _ am/pm
Results ______am/pm
Lower Explosive Limit (LEL) (0%)
Initial Results am/pm
Results _ am/pm
Results _ _ am/pm
Results ______am/pm
Hydrogen Sulfide (0 ppm)
Initial Results am/pm
Results _ am/pm
Results _ _ am/pm
Results ______am/pm
Carbon Monoxide (Oppm)
Initial Results am/pm
Results _ am/pm
Results _ _ am/pm
Results ______am/pm
Other
Section V - Confined Space
Not Applicable
Have confined space emergency rescue arrangements been made?
Has confined space been properly isolated?
Has exhaust generating equipment been placed away from confined space openings?
Section VI - Acknowledgements
1)_
_2)
Permit Receiver(s)
Facility Representative
Section VII - Questions to be completed on Permit Expiration or Job Completion
1. Has the job, as defined in the scope above, been completed?
Insert Date and Time
2. Have affected employees been informed the job is complete?
3. Has the equipment been returned to service?
4. Have safety devices and guards been reinstalled?
5. Have housekeeping and environmental issues been addressed?
Initials
Click here to sign
Facility Representative Close Out Signature
Click here to sign
Date and Time
Source: Ergon - Manor (Community Member)