RETAIL PERMIT TO WORK SYSTEM – WORK CLEARANCE FORM

General Information Tick the applicable IOGP Life Saving Rules

for this activity
Date:……………….……………………………………………………….
Person undertaking work:…………………………………….................
Job / Work Order No.:.……………………………………………….........
Company:……………………………………………………………………
Site Address:………………………………………………………………
Minimum level of PPE to be worn / used at all times. Tick for confirmation

Work to be done: ………………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………….............

HIGH RISK ACTIVITY (PERMIT+ Job Hazard Analysis) MEDIUM RISK ACTIVITY (Job Hazard Analysis) OTHER
Consult “Appendix 2 - Retail Permit to Work - Activity Table” or your supervisor for more information
Permit No.: ……………….. JHA Reference No.: ……………….. JHA Review No.: ………………..

Hazards and Controls

Tools / equipment to be used (e.g. hand tools, mechanical tools, plant etc): ……………………………………...................
……………………………………………………………………………………………………………………………………,……….
…………………………………………………………………………………………………………………………………….……….
Hazards (e.g moving vehicles, electrocution etc.) and Controls (e.g guardrails, barricading, lockout/tag out, etc). Note: For Medium or High
Risk activity refer to the JHA for further details. The Predetermined JHA must be reviewed for the work that will occur EACH DAY that the permit is open. The Permit
Holder must ensure that any changes have been Risk Assessed and the Permit and/or associated JHA is updated to reflect changing conditions.

Hazards Controls Comments

Personal Protective Equipment (PPE) appropriate to the task: ……………….……………………………………………………………..

………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………....
Fire extinguisher(s) located at: …………………………………………………………….……………………………………………..

Remember to carry out the Last Minute Risk Assessment before and during any task
ACKNOWLEDGEMENT OF WORK – CONTRACTOR
The contractor acknowledges that the job will be performed in line with the precautions listed above, that all proposed work has been discussed with the Site Representative,
and that the Site Representative will be informed of any incidents
Contractor Site supervisor certify that the work crew have a valid Safety Passport and can perform work at a Shell Retail location

NAME: SIGNATURE: TIME: DATE:

ACKNOWLEDGEMENT OF WORK CREW - The work crew acknowledges that they understand and will comply with the precautions listed above (not required for medium
and high risk activities)
SIGNATURES

ACKNOWLEDGEMENT OF WORK - SITE REPRESENTATIVE

The Site Representative witnesses the Contractor's signature and agrees to inform the Contractor of any change in site conditions such as tanker delivery or delivery of
food goods

NAME: SIGNATURE: TIME: DATE:

WORK CLEARANCE CLOSE OUT - CONTRACTOR
The contractor acknowledges that the job has been completed / suspended and the site has been left in a safe and satisfactory condition.

NAME: SIGNATURE: TIME: DATE:

WORK CLEARANCE CLOSE OUT - SITE REPRESENTATIVE
The Site Representative acknowledges that the job has been completed / suspended

NAME: SIGNATURE: TIME: DATE:

Appendix 4 - Shell Retail Permit to Work _ Version 5.1

 RETAIL PERMIT TO WORK SYSTEM – JOB HAZARD ANALYSIS

Date:
Will the work involve any of the activities below? (Circle any that apply)
If ‘YES’ a Permit must be obtained
Prepared by:
Hot work in Hazardous areas Confined space entry Excavation >/= 1.2 m
Company:
Inerting or Gas Freeing Work on Flammable Live Electrical Work
Retail Station Address:
Gas Systems
Asbestos Work Explosive Blasting Other (specify):

JHA Reference No.: ___________________________ JHA Review No.: _____________________________

Predetermined JHA shall be verified and reviewed on site every day before performing the work.

Description of work and number of days anticipated :

____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________

Step No Job Step Job Step Hazard Job Step Control

Shell Retail Permit to Work _ Version 5.1

 RETAIL PERMIT TO WORK SYSTEM – JOB HAZARD ANALYSIS

Personal Protective Equipment (PPE) appropriate to the task at hand shall be worn/used at all times.
Tick box any PPE that applies to this job

Any additional PPE appropriate to the task :

List required equipment / tools (e.g fire extinguisher, barricading / signs , hand tools, mechanical tools, plant etc.):

The work crew acknowledges that they understand and will comply with the precautions listed above

NAME: SIGNATURE:

NAME: SIGNATURE:

NAME: SIGNATURE:

NAME: SIGNATURE:

NAME: SIGNATURE:

NAME: SIGNATURE:

Shell Retail Permit to Work _ Version 5.1

 RETAIL PERMIT TO WORK SYSTEM – PERMIT TO WORK

A copy of this Permit along with any applicable attachments must be readily available at the work site

Site Address:……………………………………………………………………
Site Representative:……………….…………………………………………..
Site Phone:……………………………………………………………………... Permit No.: ………………

Permit Issuer: …………………………………... Permit Validity From (dd/mm/yy): ……………………………

Permit Issuer phone: …………………………………... Permit Validity To (dd/mm/yy): ……………………………
Permit Holder: …………………………………... Time From: ……………………………
Permit Holder phone: …………………………………... Time To: ……………………………

The activities below apply to the work ( Tick those activities that apply )
__Hot Work in Hazardous areas __Work on Flammable Gas Systems _Explosive Blasting
__Confined Space Entry __Live Electrical Work __Other (Specify) ……………………
__Excavations > / = 1.2 meters __Asbestos Work …………………………………….
__Inerting or Gas Freeing

Equipment Isolation Responsibility (LOTO)

Equipment to be Isolated: Isolation Established by: Isolation Withdrawn by:
Electrical / Mechanical / Fluid Date Time Printed Name, Signature & Date Time Printed Name, Signature &
Company Company

Equipment Re-commissioning responsibility / instruction: ..........................................................................................

..............................................................................................................................................................................................
..............................................................................................................................................................................................

Emergency Response:
Phone Numbers : Location of nearest medical facility…………………………………………………
Fire: ............................................. Emergency meeting point: …………………………………………………………..
Police: ………………………………
Ambulance: ………………………… Other:…………………………………………………………………………………..
Additional hazards and controls that are not documented in the WCF and in the JHA :
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………...
……………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………..
Other documents and attachments applicable to this Permit are (e.g JHA, gas testing records, legal permits etc.):

………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
Signature Company Date Time
Permit acceptance by Permit Holder: …………………… …………………… …………………… …………………
Permit authorized by Permit Issuer: …………………… …………………… …………………… …………………
Permit close out by Permit Holder: …………………… …………………… …………………… …………………
Permit close out by Permit Issuer : …………………… …………………… …………………… …………………

Appendix 5 - Shell Retail Permit to Work _ Version 5.1