1. Work Permit  Meraux Refinery  Cold Work Low Energy  Yes  N/A
Permit Number:
Information to be completed by Permit Holder
Company:
 Meraux Refinery
Contractor Name 
Area/Unit
Permit Holder:
Tools/Equipment to be used:
Equipment #
# Persons: Work Order #:
Hand tools
Lift trucks
Double Insulated Electric
Other:
Scope of Proposed Task:
Please initial that the Scope of work is clear and understood. Permit Holder: Permit issuer:
Information to be completed by Permit Issuer.
Previous Product
in Equipment:
MSDS Checked
 Yes  N/A
Additional
PPE Required?
Equipment Pre-Work
Req’d
Done
Area Preparation
LOTO Procedures Followed
Y -- N
Lock Box Number:
Bottle Watch / Additional Standby
Blinded/Disconnected
Blinds Verified & Blind-List initialed
Equipment Opened/Depressurized
Decontamination
Low energy work Preparation
Valves-Closed/Tagged/Chained/Locked
Water Washed
Lighting 120 V w/ GFCI
Electrical Systems
N2 Purged
Prepared for Vehicle Entry
Field Test / Attempt to Energize-start
Steamed
Sumps-drains covered
Radioactive Sources Secure
Electrical Connections Taped
Job Hazards Y
Standard Controls
PPE
Req’d
Access & Egress
Housekeeping, Walkways, Stairs
Manual Handling / Lifting
Assessment & lifting equipment
Standard (SSP-0011)
Activities of Others
Communications, Barriers, Permit
Moving Parts
Covers, Isolation, & Maintenance
Full Face Shield
Chemical /Fuel Exposure
MSDS Review, PPE
Overhead Hazards
Labelling, Isolation, & Barriers
Goggles
Vehicle Entry
Procedures, Barriers, & Permit
Sharp Edges
Covers, PPE, & Equipment Inspections
Hearing Protection
Electricity
Isolation, LOTO
Slips, Trips & Falls
Housekeeping, & PPE
Fall Protection
Flammable Vapors / liquid
Gas Testing & Isolation
Static Electricity
Grounding,
Rubber /Leather Gloves
Fumes & Dust
Respirator / Eye Protection
Trapped Pressure
Venting, Draining, & PPE
Rubber Gloves
Hot Surfaces
Insulation / Barriers / PPE
Vehicle Traffic
Hi-Vis Clothing, Speed Limit, & Signs
Non Permeable Suit
Toxic Vapors / Liquids
Underground Hazards
CAT Testing, Labelling, & Barriers
Respirator ½ face
Spillage to Ground
Secondary Containment
Hot Liquid
Procedures & PPE
Respirator Full Face
Spillage to Water
Containment / Booms
Working at Height
Scaffolding & Fall Protection / Harness
Supplied Air
Working Over Water
Life Jacket, & Safety Boat,
Personal H2S monitor
Mechanical Lifting
Barriers / Lift Procedures
Other
Specific Hazards:
Additional Controls and/or Special Instructions:
Air testing is required for low energy – non- Hot Work permitted activity. (Chief Operator must be notified.) No
Date
Time
%LEL
Oxygen
H2S CO
Benzene
Other
Serial No
Meraux Qualified Person 1 2
Signing this Work Permit signifies the job site has been inspected by the Permit Issuer and Permit Holder, the area is prepared, and each individual has agreed to comply with the conditions of this permit.
The Permit is valid through the end of the current work shift (start and end times below) and may be extended into the next shift if necessary.
All Signatures are Required
PRIOR to INITIAL work.
Time Start
Time Expires
Authorized Start
Print Name
Signature
Date
Permit Holder
Permit Issuer
Chief Operator (if required)
All Signatures are Required
PRIOR to EXTENDING
Permit into the following shift.
Time Start
Time Expires
Authorized Continue
Print Name
Signature
Date
Permit Holder
Permit Issuer
Chief Operator (if required)
Permit End
Work Completed
Work Site in Safe & Clean Condition
Print Name
Signature
Date
Time
Permit Holder
Yes No
Yes  No
Unit Operator

2. Work Permit  Meraux Refinery  Cold Work Low Energy  Yes  No
Permit Number:
Please designate if this is “Cold Work” or if Low Energy which includes only Vehicular Entry into a unit or low voltage only work.
Please see hot work permit instructions
The Permit Holder completes this section of the permit prior to meeting wit permit issuer.
Information to be completed by Permit Holder
Company:
 Meraux Refinery
Contractor Name 
Area/Unit
Permit Holder:
Work Order # (s):
Equipment #
# Persons:
Scope of Proposed Task:
Check if Meraux personnel doing work
Check and indicate Contractor Name for contractor work
Person responsible for the work to be completed directly supervising the work. Must participate with the permit issuer in reviewing the area
How many will be involved performing work
Indicate work order numbers
The Permit Holder should describe the scope of work to be completed in this area.
Information to be completed by Permit Issuer.
Work Description:
Previous Product
in Vessel:
MSDS Checked
 Yes  No
Comment:
Permit Issuer is an operator for the area involved
The permit issuer should describe the work and ensure that their understanding of the work and the understanding of the Permit Holder are the same.
Indicate what product was last in vessel to ensure proper PPE can be accessed.
<< Indicate if the MSDS was checked for the previous product in the vessel – then make any relevant comments in this area.
Equipment Pre-Work
Req’d
Done
Area Preparation
LOTO Procedures Followed
Lock Box Number:
Bottle Watch / Additional Standby
Blinded/Disconnected
Blinds Verified & Blind-List initialed
Equipment Opened/Depressurized
Decontamination
Low energy work Preparation
Valves-Closed/Tagged/Chained/Locked
Water Washed
Lighting 120 V w/ GFCI
Electrical Systems
N2 Purged
Prepared for Vehicle Entry
Field Test / Attempt to Energize-start
Steamed
Sumps-drains covered
Electrical Connections Taped
The Permit Issuer and Permit Holder work through this section to ensure that:
1 – all Equipment Pre-Work area are checked to indicate what is REQUIRED (Req’d)
2 – to ensure that all REQUIRED Pre-Work is actually DONE
The permit issuer and Permit Holder also ensure area preparation is required and Done for Bottle Watch or Low Energy Work.
Job Hazards Y
Standard Controls
PPE
Req’d
Access & Egress
Housekeeping, Walkways, Stairs
Manual Handling
Assessment ,& Equipment
Standard (SSP-0011)
Activities of Others
Communications, Barriers, Permit
Moving Parts
Covers, Isolation, & Maintenance
Full Face Shield
Chemical /Fuel Exposure
MSDS Review, PPE
Overhead Cables
Labelling, Isolation, & Barriers
Goggles
Vehicle Entry
Procedures, Barriers, & Permit
Sharp Edges
Covers, PPE, & Equipment Inspections
Hearing Protection
Electricity
Isolation, LOTO
Slips, Trips & Falls
Housekeeping, & PPE
Fall Protection
Fire & Explosion
Gas Testing & Isolation
Static Electricity
Grounding,
Chemical Gloves
Fumes & Dust
Filter Mask, Eye Protection
Trapped Pressure
Venting, Draining, & PPE
Chemical Suit
Hot Surfaces
Procedures & PPE
Vehicle Traffic
Hi-Vis Clothing, Speed Limit, & Signs
Respirator ½ face
Underground Cables
CAT Testing, Labelling, & Barriers
Respirator Full Face
Environmental
Yes No
Hot Liquid
Air Supplied Hood/Line
Can product contaminate soil/water?
Working at Height
Hand Rails, Harness, & Life-Line
SCBA
If yes, have preventive measures been taken?
Working Over Water
Life Jacket, & Safety Boat,
Personal H2S monitor
Is secondary containment required?
Other..
The Permit Issuer and Permit Holder also inspect the area for Job Hazards. In this area if a Job Hazard exists the box should be checked. Standard Controls or other appropriate measures should be taken to ensure the area is safe for work.
Also – potential Environmental impacts are noted below:
Based on the work and hazards – specific required PPE should be Identified for the permitted work.
Additional Controls Required:
Special Instructions:
Additional controls that are required and implemented should be described in this section.
Any additional or special Instructions should be noted in this section.
Air testing is required for low energy – non- Hot Work permitted activity. If test are taken, Chief Operator must be notified. No
Date
Time
%LEL
Oxygen
H2S CO
Other
Serial No
Meraux Qualified Person: 1 2
A Meraux employee (or designated contractor during turnaround events) who is qualified to do air testing must test the work area prior to any Vehicle entry or other low energy work being performed for this permit. These readings are noted here. A signature is required
Signing this Work Permit signifies the job site has been inspected by the Permit Issuer and Permit Holder, the area is prepared, and each individual has agreed to comply with the conditions of this confined space permit.
The Permit is valid for a period of up to 12 hours (start and end time below) or may be extended (below) for up to 24 hours.
All Signatures are Required
PRIOR to INITIAL work.
Time Start
Time End
Authorized Start
Print Name
Signature
Date
Permit Holder
Permit Issuer
Chief Operator (if required)
All Signatures are Required
PRIOR to EXTENDING
permit up to 12 hours
Time Start
Time End
Authorized Continue
Print Name
Signature
Date
Permit Holder
Permit Issuer
Chief Operator (if required)
These names, signatures and date must be complete and the Start and End time for the permit set (above) prior to work start.
If, at the end of the shift, it is necessary to extend the permit, the on-coming Permit Holder and Issuer must review the area to ensure conditions have not changed and re sign the permit with start and end times.
Permit End
Work Completed
Work Site in Safe Condition
Print Name
Signature
Date
Permit Holder
Yes No
Yes  No
Unit Operator
When the work is complete the Permit Holder and the Unit Operator should review the work and indicate whether it is complete and the site is in Safe condition – then print and sign their name and date the form.