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Shell WCFKris Totten2022-01-19T17:15:32+01:00

Shell WCF

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Your Name(Required)

Send This Report To:(Required)

Report Will Be Emailed to:(Required)

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Email(Required)

Enter Email Confirm Email

Date

DD slash MM slash YYYY

Person undertaking work:

Job / Work Order No.:

Company:

Site Address:

Minimum level of PPE to be worn / used at all times. Tick to confirm

Required PPE 1(Required)

I confirm my PPE meets the above requirements

Required PPE 2(Required)

I confirm my PPE meets the above requirements

Required PPE 3(Required)

I confirm my PPE meets the above requirements

Tick the applicable Life Saving Rules for this activity

Life Saving Rule 1

Select if the above is applicable

Life Saving Rule 2

Select if the above is applicable

Life Saving Rule 3

Select if the above is applicable

Life Saving Rule 4

Select if the above is applicable

Life Saving Rule 5

Select if the above is applicable

Life Saving Rule 6

Select if the above is applicable

Life Saving Rule 7

Select if the above is applicable

Life Saving Rule 8

Select if the above is applicable

Life Saving Rule 9

Select if the above is applicable

Work to be done:

HIGH RISK ACTIVITY (PERMIT+ Job Hazard Analysis)

Select if applicable

MEDIUM RISK ACTIVITY (Job Hazard Analysis)

Select if applicable

OTHER

Select if applicable

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/tagout, 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

Contractor Site supervisor certify that the work crew have a valid Safety Passport and can perform work at a Shell Retail location

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

Name

Time

Hours

:

Minutes

AM/PM

Date

DD slash MM slash YYYY

Signature

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:

Time

Hours

:

Minutes

AM/PM

Date

DD slash MM slash YYYY

Signature

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:

Time

Hours

:

Minutes

AM/PM

Date

DD slash MM slash YYYY

Signature

WORK CLEARANCE CLOSE OUT - SITE REPRESENTATIVE

The Site Representative acknowledges that the job has been completed / suspended

Name:

Time

Hours

:

Minutes

AM/PM

Date

DD slash MM slash YYYY

Signature

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