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27f-Line-Break-Permit

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					                                                                                                                                         ATTACHM ENT F
                                                              UNITED

                                              L I N E         B R E A K             P E R M I T
CONTRAC TOR N AM E                                                                                 SUPERV ISOR



W ORK L OCATIO N                                                     REQU EST OR N AME                                               D ATE




  D ESCRIPT ION OF W ORK:




  SPECIA L INS TRUCT IONS:




   PE RSON AL P RO TECTION EQU IP MEN T REQU IRED        CH ECK                             OTHER P ROTECTION                                       CHECK
                                                        YES     NO                              METHODS                                      Y ES        NO
Air P ack – Approved                                                     Barri cad e - _ _ _ _ _ _ __ _ Rad i us ( Above /Be low)
Boots – Rubber Boots                                                     Blanks To Be Installed
Coveralls -Tyvek                                                         Block Valve Shut
Film Badge                                                               Blower
Glove – Long Gloves                                                      Fire Extinguisher
Gloves – Leather Gloves                                                  Grating, Floor Opening Covered
Gloves – Rubber Gloves                                                   Lock Out P lan Required
Goggles                                                                  P iping Support Installed/Needed
Hood – Acid Hood                                                         P lanning (Line Break Planning Items Page 2 completed and
                                                                         distributed to all personnel involved)
Respirator – Full Face Respirator
Respirator – Half Face Respirator                                        P ump Locked Out
Shield – Face Shield                                                     Spark P roof Tiles
Shield – Special Shielding                                               Standby P erson
Suit – Acid Suit                                                         System Less Than 100 degrees C.
Suit – Hot Suit                                                          System Vented

Suit - Rain                                                              Valve Locked Out
Other:                                                                   Water Hose
Other:                                                                   Other:
Other:                                                                   Other:
Other                                                                    Other:
Other:                                                                   Other:

                                                    A P P R O V A L S I G N A TU R ES

                            A PPR OVER                                                SIGN ATUR E                                                    D ATE
CLI ENT O P ER AT IONS R EPR ES EN TAT IV E

FLUOR SU PER V ISON

P ER SON MAKI NG BR E AK

P ER SON MAKI NG BR E AK




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                                                                                                  ATTACHM ENT F

                                                 PLANNING ITEM S FOR LINE BREAKS


1.     De-pressurizing, Cleaning, and Venting Check


2.     Nearest Safety Shower Location (If greater then 50 feet, water
       hose will be provided)


3.     Nearest Eyewash Location


4.     Cold Pak Location


5.     Scott Air Pak Location


6.     Fire Extinguisher Location


7.     Fire Alarm Location


8.     Stretcher Location



9.     Planned Escape Route



                                   RELAXING PERSONAL PROTECTIVE EQUIPM ENT REQUIREM ENTS

Date:                                                                   Time:
Personal Protective Equipment Reduced To Items Shown Below:




                                                           APPROVAL SIGNATURES

                   Approver                                                Approver’s Signature       Date

Client Operations Representative
Supervisor
Person Making Break
Person Making Break




     D:\Docstoc\Working\pdf\235a7606-23dd-49aa-a7a3-c73b054d48f9.doc                                   Page 2 of 2

				
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posted:4/29/2011
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