Manway and Appendage Removal Permit

Date

Tank Number

What is being removed?

• Manway

• Thermowell

• Sample valve

• Other

Have the following operating procedures been completed? LO/TO, JHA, Safe work permit

• Yes
• No
• N / A

LO/TO Permit Number

Safe Work Permit Number

Has the tank been hand gauged to verify the liquid level?

• Yes
• No
• N / A

A) Tank Gauge Height

B) Hand Gauge

C) Record other instrument measurements (i.e. radars, Varec, gauge board, etc.)

D) Record the difference between tank gauge height and hand gauge: A-B=liquid level height

E) Measure the height from the outside annular chime of the tank to the bottom of the manway/appendage height

Record difference between manway/appendage and liquid height: D-E=difference

Manway/appendage cover SHALL NOT be removed UNLESS the product level is under the bottom of the manway/appendage height

• Yes
• No
• N / A

What's the tank temperature?

Are ALL affected employees aware of the hazards of manway/appendage removal?

• Yes
• No
• N / A

Employee Signature

Manager/Supervisor Signature