FORMAT: DANGEROUS WORK PERMIT Date: Start time: End time:

Work permit valid for a maximum of 12 hours

Nombre de la unidad: No. Determinant: Area where the work will be carried out:
UNIT DATA

PERSONAL DATA AND TYPE Name of supplier and/or contractor: Name and surname of the resident work/crew leader/supervisor of the job:
OF DANGEROUS WORK

Name and surname of the supplier/contractor/partner who performs the work Name and surname of the red helmet of the contractor:
1)
2) Check the box of the work to be done:
3) X Delete the work that will be done
4) Work at heights Electrical work Chemical work
5) Hot work Confined space Another:
6) Description of the activity to be carried out:
Fire sentinel name by front/work area provider/contractor/associate
1) In case of an accident report to:
2) Tel:

SAFE TASK ANALYSIS - SECURITY MEASURES

STOP! THINK ACT!

Identify and describe the main activities Risk controls to be executed - Safety measures. Consult the work manual.
Risk identification Apply
high-risk to be done step by step or the safety procedures or the STPS regulations.
1. Fire
2. Falls from different levels
3. Same level falls
4. Bumps/bruises
5. Trapping
6. Exposure to chemicals or fumes
7. Intoxication/asphyxia
8. Poor ventilation
9. Excessive physical effort
10. Electric shock/electrocution/electrical contact
11. Generation of hazardous or non-hazardous waste
12. Spills
13. Drownings
14. Noise, lack of lighting or high temperatures
15. Deficient oxygen/inflammable atmosphere
16. Vehicle movement
17. Another:

WORK PERMIT AUTHORIZATION - NAME AND SIGNATURE As applicable SUPERVISION OF WORK

I have seen and validated that the security measures are being met according to the risks.
Person in charge of the activity (Supplier: Site resident/crew leader. Store-Club:) Store/Club manager/store chief: Write down the data that applies to you and Asset Protection Other (example: Staff,
Red helmet supervision Red helmet contractor
cross out the data that do not apply to you CEDIS: PAL / SL Supplier or Contractor

Red helmet of the concentrator/Supplier Asset Protection/PAL: Name, first

apellido/Hora/Firma
SIMA/maintenance: CEDIS Medical Service Name, first
apellido/Hora/Firma
CEDIS Responsible for the area (manager or deputy manager): Another: Name, first
last name/Time/Signature
 FORMAT: DANGEROUS WORK PERMIT

USE OF PERSONAL PROTECTIVE EQUIPMENT ACCORDING TO THE TYPE OF HAZARDOUS WORK

If a box in the PPE selection is empty, work will not be allowed until the required PPE is completed according to the identified risks.

Apply Apply Apply Apply Apply

HOT WORK Yes / No ELECTRICAL WORK Yes / No WORKING AT HEIGHTS Sí / No Chemical Work Sí / No CONFINED SPACES Sí / No

Welder's helmet Dielectric helmet Full body harness Overall or long sleeve shirt and pants Full body harness
Leather gloves and sleeves Dielectric safety footwear Línea de vida autoretráctil Suit for chemical substances Rescue lifeline and tripod
Mask with filters for welding fumes Dielectric gloves Lifeline with or without absorber Nitrile gloves Safety glasses or goggles
Jumpsuit or long-sleeve shirt and pants Overalls or long sleeve shirt Helmet with chin strap Mask with filter for gases or chemical vapors Coverall or long-sleeve shirt, pants or Tyvek suit
Leather apron and denim nun and cotton pants Safety glasses Goggles or safety glasses Helmet with chin strap
Safety footwear Face shield or safety glasses Safety footwear Safety data sheets for chemical substances Safety footwear
Impact helmet Electric current tester Deerskin gloves or HyFlex Respirator for chemicals or dust Gas meter
Ear plugs Another: Overall or long sleeve shirt and pants Another: Means of communication
Another: Another: Another:

SAFETY MEASURES ACCORDING TO THE TYPE OF DANGEROUS WORK

If a cell is empty, work will not be allowed until the required items are completed according to the identified risks.

Apply Apply Applies Applies Apply

HOT WORK Sí / No ELECTRICAL WORK Sí / No WORK AT HEIGHTS Sí / No CHEMICAL WORK Yes / No CONFINED SPACES Sí / No

BEFORE BEFORE BEFORE BEFORE BEFORE

The area is defined and clear. The equipment, board, or line was identified. The work area is defined. Safety data sheets are available. Written authorization from management is available.
of combustible and flammable materials electric where work will be done and is available of the chemical substances to work with for entry into the confined space and the area is delineated.
within a radius of 10m with a single line diagram
The worker has a tool holder
It was de-energized and locked out (padlock) to secure the tools The PPE was reviewed: chemical gloves, suit Gas measurement was carried out with a gas detector.
Partitions made of materials were placed. within the confined space, at three different levels
no flammable materials and fireproof tarps your card) the line, equipment or element for chemical substances, mask,
respirator and goggles (baja/intermedio/superior)
electric to intervene (LOTO was applied)
The checklist for the lifting equipment was completed.
There are two CO2 or PQS fire extinguishers. (genie, scaffolding, and ladders)
The absence of energy was confirmed. An additional rescue line is available.
in the workplace The area where the work will be carried out has been delimited.
at the entrance
electrical, with a voltmeter or tester
It was verified that there are no cracks in which current The PPE was reviewed: harness, lifeline, helmet
the spark generation ignites a small fire with chin strap and safety shoe The spill kit is available. The blocking of the different energies was carried out.
There are two CO2 fire extinguishers.
of fire and the staff is trained to enter the confined space
in the workplace
Notification was given to asset protection (PA/PAL) There is a PQS fire extinguisher. There is lighting and ventilation according to
The Fire Alarm Protocol was applied. It was verified that all the tools to open access to the roof in the workplace the risks of confined space
Fire Watch and stairs are dielectrics
DURING DURING DURING DURING DURING
The sentinel is attentive to the activity It is verified again that the line, equipment Anchor points must be installed Gas measurements are conducted in space
Use the PPE according to the activity
at risk the electrical panel is de-energized roof or where required confined in intervals of 10 minutes
The sparks generated do not reach. The contractor who does the work Ventilate the area where the work is being done
The workers who do the work must
to combustible materials electric, use your specific PPE A 10-minute break is given to the contractors every 30 minutes.
to be anchored to a fixed point at all times
The worker who is doing the job When working with chemicals
hot uses its PPE and complies with Maintenance or the electrical resident Constant supervision is required hot work cannot be carried out The lookout is aware of the risk activity and knows
supervises the work periodically in the different jobs in the same area what to do in case of an emergency
the different security measures
AFTER AFTER AFTER AFTER AFTER
Contractor / Supplier / Associate reviews the area Notice will be given that the work is finished Work must be suspended in the presence of The work area will be left in order,
after work: to maintenance or to the electrical resident rain, strong winds or very hot environment cleaning and in safe conditions The work area will be left in order and clean.
and it energizes again and in safe conditions
The workspace is left orderly and clean. All hazardous waste generated
The workspace is left tidy, they must be arranged according to the
___1 hr ___2 hr. ___3 hr. and in safe conditions
cleaning and in safe conditions defined procedures
To discard possible ignition (fire starting). All equipment will be delivered in good condition.
Notify asset protection (PA) for Notify Management of the completion of the work
Mark with an X each inspection hour. estado, conectados, aterrizados, Waste chemicals must be
protective covers and guards
that they close off access to the roof store in a safe area

CLOSING OF THE WORK PERMIT - NAME AND SIGNATURE

Asset Protection/PAL: Red helmet of the contractor:

Store Management / Club: Red helmet of the supervision:
Resident of the work or crew leader:

ACCIDENT-FREE PRODUCTION IS POSSIBLE!

I LIVE SECURITY!