SOW_15-5G3 Attachment_Work_Permits_5M15G301.pdf

SOW 15-5G3, DMEA Work Permit Form (Hot Work, Odorous Work, Electrical Work, Confined Space)

To be completed by the DMEA OPR

Company Name Date Company Telephone Number

Planned Duration

Start Time:

Stop Time:

Technician(s) Name(s) and Cell Phone Number

Describe Work (Continue on pg. 2 if necessary)

Work Location and Systems Involved

Chemicals/gases involved

Gas sensors in area? Smoke Detectors in area?

Precautions (check all that apply) Potential Dust Generation in/near Cleanroom – Get Cleanroom Briefing from MEBB

Confined Space/Buddy System Responsible Buddy name:

Emergency support/evaluation equipment required (list eg. Two-way radio, harness)

List

Technicians to have fire extinguisher, emergency numbers (911 and 231-1667*) and know where emergency equipment and telephones are located as well as evacuation routes and assembly areas

Combustible materials removed/shielded List

Equipment purged of chemicals/combustibles/flammables (list)

Equipment

Gases shutdown and lines/equipment purged

30 minute fire watch after work complete with fire extinguisher and water source on-hand

Covers suspended beneath work to collect sparks

Other special precautions (describe use additional sheets if required):

Electrical Work: Equipment to be shutdown (non-energized) and locked out and tagged out Electrical Work: Energized – Contractor to provide all necessary safety equipment and procedures Individuals (list) to be with present valid first aid/CPR card:

Names:

Area Inspected to prevent fire IAW NFPA 51B Name:

Signature

Briefing to technicians on the DMEA fire and gas alarm system and emergency procedures

DMEA Briefer Sign once briefing conducted:

DMEA OPR notify required POCs IAW DMEA Security OI 5200 Sec. 13.3

Names:

OPR:

*NOTE: Contact the DMEA Security Booth at 1667 (DMEA phone) or (916) 231-1667, in the event of an emergency (after calling 911). Security will assist the first responders (Fire, Ambulance/EMT, etc.) .

Additional notes (include continued paragraph):

DMEA OPR Signature ________________________________ Date:________________________________

Contractor Signature__________________________________ Date:________________________________

DMEA Approval Signature _____________________________ Date:________________________________

Work Complete and Precautions followed certification:

Contractor Signature__________________________________ Date:________________________________