WORK PERMIT DOCUMENT REVIEW CHECKLIST
Date:
Work Permit #:
Critical Procedures – Critical Procedures applicable to the mechanical work are to be identified below or check the N/A box if none are applicable:
Confined Space Entry
Nitrogen Purging, Isolation & Recommissioning of Pipelines
(PDM 03-02-02)
(PDM 03-02-20)
Tank Cleaning and Maintenance / Site Activities
Drain Down a Pipeline
(PDM 03-02-03)
(PDM 03-02-21)
Energy Isolation and Lockouts
Pipeline Cutouts
(PDM 03-02-05)
(PDM 03-02-22)
Hot Tapping
Penetration of Pressure Piping
(PDM 03-02-06)
(PDM 03-02-23)
Vapour Recovery Bed Burn-In
Weld on Sleeve Procedure
(PDM 03-02-07)
(PDM 03-02-24)
Cranes and Lifting Operations
Lowering Live Lines
(PDM 03-02-09)
(PDM 03-02-25)
Entering on Internal Floating Roofs – Tanks
Stoppling Procedure
(PDM 03-02-10)
(PDM 03-02-26)
Excavations
Freeze Plug Installation
(PDM 03-02-12)
(PDM 03-02-27)
Mechanical Plugs
Grinding on Live Lines
(PDM 03-02-13)
(PDM 03-02-28)
Landing & Raising Floating Roofs – Continued Service
Cleaning and Gas Freeing Storage Tanks
(PDM 03-02-14)
(PDM 03-02-30)
Landing and Re-floating Tank Roofs – Maintenance Activities
Working Around Hydrogen Sulfide (>100 ppm)
(PDM 03-02-15)
(PDM 03-02-31)
Vacuum Truck & Hydrovac Units (Hoses 4" or Greater)
Working on Pipelines under High Voltage Power Multi- Phase Lines
Hot Work in Tankfields
(PDM 03-02-32)
Working At Heights
(PDM 03-02-18)
(PDM 03-02-33)
Power Lines - Working Near
Safe Electrical Work
(PDM 03-02-19)
(PDM 03-02-34)
(PDM 03-02-16)
N/A
Worker Signoff – all workers signing on the permit confirm they have reviewed the Critical Procedures identified above.
Worker Name
533575956
Signature
Worker Name
October 2013
Signature
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WORK PERMIT DOCUMENT REVIEW CHECKLIST
Permit Issuers should ensure that all applicable PDM forms / checklists associated with the work are completed. The following list of commonly used PDM
forms/checklists has been provided to help assist in that effort, however, the list is not all-inclusive:
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0104F23
Potential Problems Analysis Tool
0302F05
Tank Entry – Internal Floating Roof – Checklist
0302F06
Excavation Pre-Job Checklist
0302F07
Equipment Lockout Record
0302F08
Blanking and Tagging List
0302F10
Plumbers Plug Checklist
0302F11
Pre-Lift Checklist
0302F12
Critical Lift Approval Form & Checklist
0302F13
Floating Roof Landing and Re-Floating Checklist
0302F14
Vacuum Truck Operation Checklist
0302F15
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0302F45
Energy Isolation - T1BP Quick Reference List
0302F46
Cranes & Lifting - T1BP Quick Reference List
0302F47
Working at Heights - T1BP Quick Reference List
0302F48
Safe Electrical Work - T1BP Quick Reference List
0302F49
Opening Process Equipment - T1BP Quick Reference List
0303F01
Safety Device Bypass Report
0307F01
Tank Entry & Gas Freeing Checklist – U/G tanks
0308F02
Piping Testing Log
0308F04
Strainer Inspection and Cleaning
0308F05
Air Eliminator Inspection
Backfilling Requirements Checklist
0308F07
Piping Commissioning Checklist
0302F16
Commissioning, Startup Safety Checklist
0308F08
Piping Decommissioning Checklist
0302F17
Purge Requirements Form
0308F10
Chemical Inhibition Trucks and Steamers Checklist
0302F18
Valve Lockout and Drawing Form
0308F11
Pigging Checklist
0302F19
Hot Tap Permit
0308F12
Excavation Equipment Requirements Checklist
0302F20
Cut-Out Requirements Checklist
0308F13
Job Safety Execution Plan
0302F21
Confined Space Equipment Checklist
0308F14
Internal Inspection During Piping Modifications
0302F31
Scaffold Pre-Use Checklist
0308F15
Thickness Measurement Location (TML) Survey
0302F32
Personnel Lift Pre-Use Checklist
0308F16
Cracking Inspection
0302F36
Lift Classification Tool
0308F19
Opening Process Equipment Checklist
0302F37
Lift Classification Quick Reference Guide
0330F03
Mobile Equipment Pre-Job Checklist
0302F 38
Non-Standard Lift Evaluation Form
0330F09
Sump Lock And Leak Checklist.
0302F 39
Non-Standard Field Observation Checklist
0302F41
Electrical Safe Work Checklist
0302F42
P&D Pipeline Interruption Request
0302F43
Confined Space Entry - T1BP Quick Reference List
0302F44
Tank Cleaning - T1BP Quick Reference List
533575956
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October 2013
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