Chapter 24.

CHECKLISTS
Manual of the Permission System for Risky Work
Key 200‐221 00‐M‐1 05‐0001, third version, December 2012

Cutting and welding works, with Oxy/Acetylene equipment or electric arc includes work with flame or spark
A1
in classified areas of risk Class I Division I and II.
A2 Frosted in classified areas of Class I, Division I and II risk.
Electrical work on installations or equipment with a voltage of 220V or higher. Likewise, all electrical work
A3
Executed in processing facilities for Class I Division I and II classified areas.
Entry into tanks or confined spaces, where there is a possibility of becoming trapped and/or where there may exist
A4 concentrations of toxic, flammable, or hazardous gases, or where the oxygen content of the atmosphere
It can be reduced below 19.5% in volume.
Handling of substances and materials hazardous to health, for example, radioactive sources, substances
A5
hazardous chemicals, asbestos, among others.
A6 Work that affects the availability of security systems and equipment.
Electrical work that includes the opening of junction boxes, cabinets, panels connected in areas
A7
risky (circuits not intrinsically safe).
Jobs that involve intervening in equipment, pipes, and systems that contain hydrocarbons or fluids
A8
risky, except for lines and accessories for instrumentation.
Lifting operations of equipment and materials close to pressurized hydrocarbon systems,
A9 installations, and/or personnel unrelated to the maneuvers.
Testing and commissioning activities for equipment that handle hydrocarbons or that may pose a threat to
A10
the safety of personnel.
A11 Diving Operations. To obtain authorization, the specific procedure must be included.

B20 Sandblasting.
Removal of paint or burrs in process installations, using manual or electric tools.
B21
pneumatic, such as reamers, bristles or rollers.
Use of hydraulic, pneumatic, or manual tools to cut metal, demolish concrete, to break up or
B22
doping in risky areas.
B23 Temporary use of internal combustion engines in hazardous areas.
Use of non-IS (non-intrinsically safe) equipment in hazardous areas, such as electric drills, phones
B24
cell phones, etc.
B25 Jobs where there is a risk of falling into water.
B26 Use of high-pressure water jets, Includes wet sand-blasting.
B27 Oil paint application with sprayers only in hazardous areas or confined spaces.
B28 Change of railings, grid systems, hatches or stairs.
B30 Work at a height of 1.80 meters or higher, except on fixed walkways.
Assembly and disassembly of scaffolding in hydrocarbon production facilities near equipment to
B31
pressure, hot or electrical installations / equipment.
B34 Use of cameras or video in processing facilities.
B36 Pressure testing of plants, pipes, and equipment.
B39 Excavations deeper than 30 cm or where underground services may exist.
B40 Launch and hoisting of lifeboats for navigation tests.
Work carried out on underground electrical records. As long as it is not considered space.
B41
confined.
Maneuvers and transport of equipment or materials whose volume or weight pose a special risk due to the
difficulty or complexity in its handling with force equipment, where the simultaneous use of 2 or
B42
more equipment (such as telescopic cranes, articulated hydraulic cranes "HIAB"; booms; fifth wheel; "towing
direct; winches, etc.).
 PERMIT No:
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SECURITY CHECKLIST No. Al
Cutting and welding jobs, with Oxy/Acetylene or electric arc equipment includes work with flame or spark in areas
risk classified Class I Division I and II.
HAZARD EVALUATION filled out by the Permit Applicant
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1. IDENTIFIED DANGERS: Add in the lines below any additional dangers you deem necessary (when required). If any danger is not...
If applicable, cancel it by crossing out (X) the corresponding danger number and also the numbers in controls.
corresponding in sections 2, 3, and 11.

1 Open flame 15 Toxic Smoke

Hot welding slag / burning splash 16 Powder
3 Hot surface (equal to or greater than 65°C) 40 Connection Failure / Pressurized Hose
6 Electric Arc 41 Gas Cylinder Failure
9 Heavy-duty energized electrical conductors 43 Electric Cable Failure
Additional dangers: ________________________________________________ _______________________________________________________

.............................................................................. ..............................................................................
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2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), annul the non-applicable ones and put the
initials of the one who evaluates the risks.
1 2 3 6 Portable fire extinguisher for class 'B'/'C' fire available on the worksite.
Have a pressurized fire hose exclusive for this job.
Verification tests for hydrocarbon gas will be conducted (specify frequency in the permit).
1 2 3 6 Continuous monitoring must be conducted for the detection of gases derived from hydrocarbons.
1 2 3 6 15 Smoke and fire detectors will be disabled at the workplace.
1 2 3 6 15 Put up barriers to prevent access to unauthorized personnel (Critical procedure for demarcating risk areas (barriers) in
PEP.
1 2 3 6 A fire safety assistant must be appointed.
Fireproof tarps (fire blanket) must be provided.
Additional controls: _________________________________________________________________________________________________________

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3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), cross out the non-applicable ones and put the initials of the person assessing the risks.
1 2 3 6 9 43 Welding gloves and/or dielectric gloves, lenses, face shields, and splash-proof clothing (when required).
15 16 41 Respiratory protection equipment (the type of protection must be specified) ________________________________________.
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4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK? YES NO
If it is elevated or cantilevered, also use list B25 or B30. If there are other risks due to the location, establish them in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permit in section 2.
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass, or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review data sheets of the Hazardous Substance and specify
controls on the Permit.
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6. Are there additional hazards due to manual material handling? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
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7. Are there any other hazards not listed above? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls in the
Permission.
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8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Instructions are generally required at the Work Site. If not, describe the reason.

Reason why they are not required:

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9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed, and it has been verified that all appropriate controls are in place.

Name
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Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No.

WORK SITE VERIFICATION filled out by the Work supervisor

10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified during the Site Inspection or the Site Instructions must be noted below and referred to in your
specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
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11. INSTRUCTIONS
Confirm by marking with X in the boxes on the right.
Containers for welding rods and used material must be used.
You must notify the Authority of the area when you are going to start the activity.
When welding or cutting in a vessel with conductive floor and walls, the welder will be protected to avoid contact.
corporal.
All areas above and below the workplace must be inspected in order to remove objects that could fall to or
from the workplace.
9-43 All electrical equipment, tools, and non-explosion-proof certified testing equipment will be verified and labeled by the
electrical manager.
9 The cables will be checked by the electrical supervisor.
1-2-3-6 The flood system must be operational and the way to operate it must be known and understood by the entire work team.
Access points and escape routes must remain free of obstacles, and alternative routes should be identified and communicated to the staff.
1-2-3-6 Flammable and combustible materials and passive fire protection coating must be removed from the work surface and area.
close.
1-2-3-6 The drainage collectors in the immediate work area must be checked and kept free of all combustible materials and protected.
with fireproof tarps (wet if necessary).
1-2-6 Put up barriers to prevent unauthorized personnel from entering (Critical procedure for delimiting risk areas)
(barricades) in PEP).
3 The supervisor must review the work area before starting activities and during their execution.
41 Gas cylinders must be secured in an upright position in well-ventilated areas and protected from direct heat. The valves of the
Cylinders must be secured to the gas regulators.
15 - 16 If the smoke and dust extraction system is required, it must be included to remove them; work must be suspended if the equipment fails.
9 The Portable team must be powered by supplies that are connected to a protected system.
43 The cables and hoses must be of a minimum length, free from temporary splices, not twisted, secured at intervals.
regular and kept away from stairs, wet areas, and hallways. They must be protected where it is not possible to cover them.
41 When not in use, gas cylinders and hose valves must be closed and should not be pressurized.
Empty gas cylinders must be placed in their specific area.
43 Electric cables should be used extended to avoid overheating.
1-2-6 The permit for this work and the certified gas test must be in place before carrying it out and during its development.
Food should not be consumed at the workplace.

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12. INSTRUCTIONS ON THE WORK SITE
The Instructions on the Work Site highlight precautions in the Permit, the assessment of Risks, and Controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Name
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13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Supervisor del trabajo

Company:...........................
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Review December 2012

 PERMIT No:
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SECURITY CHECKLIST No. A2
Grinding in Classified Risk Areas Class I, Division I and II.
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HAZARD ASSESSMENT filled out by the Permit Applicant
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1. IDENTIFIED HAZARDS: Add any additional hazards you consider in the lines below (if required). If any hazard is not
if applicable, cancel it by crossing out (X) the corresponding number for the hazard and also the numbers in controls
corresponding in sections 2, 3 and 11.

4 Mechanical spark 37 Vibration

9 Heavy-duty energized electrical conductors 40 Connection failure / pressurized hose
17 Particles (air/water) 43 Electrical Cable Failure
28 Projectiles 45 Rotary machinery or tools
Additional dangers: _________________________________________________
.............................................................................. ..............................................................................
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2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), cancel the inapplicable ones and put the
initials of the person who assesses the risks.
4 Verification tests for hydrocarbon gas will be conducted (specify frequency in the permit).
4 17 28 40 Put up barriers to prevent the passage of unauthorized personnel (Critical procedure for delineating risk areas (barricades) in

4 Continuous monitoring must be carried out for the detection of gases derived from hydrocarbons.
Additional controls:_________________________________________________________________________________________________________

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3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), strike out the inapplicable ones and put the initials of the person assessing the risks.
17 Eye protection (the type of protection should be specified) ____________________________________________________________.
17 Facial protection (face shield).
17 Respiratory protection equipment (the type of protection must be specified) _______________________________________________.
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4. ARE THERE ADDITIONAL DANGERS DUE TO THE WORK LOCATION? YES NO
If it is elevated or suspended. Also use list B25 or B30. If there are other risks due to the location, establish in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
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5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review safety data sheets of the Hazardous Substance and specify
controls in the Permit.
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6. ARE THERE ADDITIONAL HAZARDS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
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7. IS THERE ANY OTHER HAZARD NOT LISTED ABOVE? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls in the.
Excuse me.
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8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Generally YES, instructions are required on the work site. If not, please describe the reason.

Reason why they are not required:...................................................................................................................................................

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9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

Name
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Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A2
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WORKSITE VERIFICATION filled out by the Work Supervisor
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10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or Site Instructions must be noted below and referred to in your
Specific controls in section 5 of the permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
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11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or into.
from the workplace.
For electric polishers, the correct disc for the equipment's speed will be checked, and it must be grounded.
Access routes and escape routes must remain free of obstacles and alternative routes must be identified and communicated to the staff.
It must be verified that the portable electric grinder uses the appropriate voltage.
For the air-operated grinder, a standard IS103 fixed-length air hose with a Certified label will be used.
45 The machines and tools must be checked before starting work (they must be explosion-proof).
9-43 All electrical equipment, tools, and non-explosion-proof test equipment will be verified and labeled by the
electrical manager.
45 Rotating arrows and rotating discs must have protective guards.
40 The hose couplings must be secured at all points.
17 There should be a nearby eye wash station; if not, a portable station must be provided.
-34 The grounding wires must be installed and properly grounded.
17-28 Place barriers to prevent unauthorized personnel from entering (Critical procedure for delimiting risk areas
(barricades) in PEP).
9 The Portable team must be powered by supplies that are connected to a protected system.
43 The cables and hoses must be of a minimum length, free of temporary joints, not twisted, secured at intervals.
regular and kept away from stairs, damp areas, and hallways. They should be protected where it is not possible to cover them.
43 Electric cables should be used extended to avoid overheating.
40 Hoses should not be twisted during operation and must be depressurized when not in use.
43 The equipment must be de-energized and the hoses depressurized when not in use and before carrying out any
maintenance.
4 Workpieces and/or tools must be cooled with water when necessary.
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12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Work Site highlight the precautions in the Permit, the hazard assessment, and Controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

.................................................................
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13. CONTROLS ON SITE
All required controls have been verified and are in place, and the additional hazards have been noted in section 10.

Supervisor del trabajo

Company:...........................
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Review December 2012

 PERMIT No:
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SAFETY CHECKLIST No. A3
Title: Electrical work on installations or equipment with a voltage of 220V or higher. Likewise, all electrical work performed
in process installations for classified areas Class I Division I and II.
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HAZARD EVALUATION filled out by the Permit Applicant
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1. IDENTIFIED DANGERS: Add in the lines below any additional dangers you consider necessary (when required). If any danger is not
If applicable, cancel it by crossing out (X) the corresponding danger number and also the numbers in control.
corresponding in sections 2, 3, and 11.

3 Hot surface (equal to or greater than 65°C) 10 Static electricity

5 Electric Spark 11 Power supply interruption
8 Energized electrical conductors (fixed) 43 Electric Cable Failure
9 Heavy-duty energized electrical conductors 45 Rotary machinery or tools
Additional hazards: __________________________________________________
........................................................................................ ..............................................................................
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2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), cancel the inapplicable ones and put the
initials of the person who assesses the risks.
8 10 The equipment will be isolated and grounded in accordance with electrical safety standards.
3 5 Portable extinguisher for class "B"/"C" fire available on the work site.
3 5 Gas verification tests for hydrocarbons will be carried out (specify frequency in the permit).
3 Smoke and fire detectors will be disabled at the workplace.
3 8 Place barriers to prevent access to unauthorized personnel (Critical procedure for delimiting risk areas (barricades) in PEP).
3 5 Continuous monitoring must be carried out to detect gases derived from hydrocarbons.
3 A fire assistant must be appointed.
3 Fireproof blankets (firefighting blanket) must be provided.
8 10 Access Limitation, Permit for electrical work and Grounding Conductivity Test (invalidate inapplicable documents).
Additional controls:_________________________________________________________________________________________________________

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3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), strike out the non-applicable ones and put the initials of the person evaluating the risks.
1 3 Welding and/or dielectric gloves, lenses, face shields, and splash-proof clothing (where required).
8 Rubber gloves suitable for the electrical voltage required to perform the job.
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Are there additional hazards due to the job location?
If it is at height or suspended, also use list B25 or B30. If there are other risks due to the location, establish them in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
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Are there additional dangers due to substances used? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review Safety Data Sheets for the Hazardous Substance and specify
controls in the Permit.
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6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
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YES NO
7. IS THERE ANY OTHER UNLISTED DANGER?
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Identify additional hazards in section 1 and specify controls on the
Permission.
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YES NO
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE?
Instructions are generally REQUIRED on the Job Site. If not, describe the reason.

Reason why they are not required:

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9. COMPREHENSIVE ASSESSMENT OF THE RISKS OF THE ACTIVITY (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

..........................................................
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Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A3
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WORKSITE VERIFICATION filled out by the Work supervisor
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10. ADDITIONAL DANGERS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or the Site Instructions must be noted below and referred to in your
In case of Specific controls in section 5 of the Permission by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
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11. INSTRUCTIONS
Confirm by marking with an X in the boxes.
Access points and escape routes must remain free of obstacles, and alternative routes should be identified and communicated to staff.
All areas above and below the workplace must be inspected in order to eliminate objects that could fall to or from it.
workplace.
45 Machines and tools must be checked before starting work (they must be explosion-proof).
43 All electrical equipment, tools, and unapproved explosion-proof testing equipment will be verified and labeled by the
electrical manager.
5-9 The cables will be checked by the electrical manager.
45 Rotating arrows and spinning disks must have protective guards.
8-10 Electrical insulations must be installed and labeled.
9-43 The grounding cables must be installed and properly grounded.
3 The drainage collectors in the immediate work area must be checked and kept clean of all combustible material and protected with
fireproof tarps (wet if necessary).
3 The supervisor must review the work area before starting activities and during their execution.
5-9 The Portable team must be powered by supplies that are connected to a protected system.
8 Insulating mats must be used at electrical terminals.
43 Power supply must be considered in cases deemed necessary through relay equipment.
43 The cables and hoses must be of a minimum length, free of temporary joints, untwisted, secured at regular intervals and
kept away from stairs, damp areas, and hallways. They must be protected where it is not possible to cover them.
8 Covers or lids must be placed at the workplace if you are going to leave it, even for short absences.
43 Electric cables must be used extended to avoid overheating.
10 The grounding connection must be installed and tested before starting any work.
43 The equipment must be de-energized and the hoses depressurized when not in use and before carrying out any
maintenance.

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12. INSTRUCTIONS AT THE WORKSITE
The Instructions on the Work Site emphasize the precautions in the Permit, the Risk Assessment and Controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Name
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13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Job Supervisor
Company:...........................
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Review December 2012

 PERMIT No:
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SAFETY CHECKLIST No. A4
Title: Entry into tanks or confined spaces, where there is a possibility of becoming trapped and/or where there may be
concentrations of toxic, flammable, or hazardous gases, or where the oxygen content of the atmosphere may be
reduced below 19.5% in volume.
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HAZARD ASSESSMENT filled out by the Permit Applicant
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1. IDENTIFIED HAZARDS: Add any additional hazards you consider necessary in the lines below (when required). If any hazard is not
Applicable, annul it by crossing out (X) the corresponding number for the danger and also the numbers in controls.
corresponding in sections 2, 3 and 11.

12 Liberation of Hydrocarbons 24 Lack of Oxygen

14 Toxic Gas 34 Poor visibility / lighting
16 Octopus 99 Reduced access
Additional dangers: __________________________________________________
............................................................................................ ............................................................................................
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2. PERMISSION CONTROLS: The following controls must be specified in the Permission (sections 3, 4, and 5), cancel those that are not applicable and include those.
initials of the person who assesses the risks.
12 14 24 Conduct oxygen and/or toxic gas tests (specify type of gas). Work must be suspended if the oxygen level drops below 19.5% or
if continuous monitoring fails.
12 14 24 Place barriers to prevent unauthorized personnel from entering (Critical procedure for delineating risk areas (barricades) in
PEP).
12 14 24 The system must be isolated and the isolation certificate must be placed in a visible location.
12 14 24 An authorized certificate is required to enter a confined space and must be visible at the work site.
34 Explosion-proof lighting must be provided.
99 There should be a responsible observer in permanent contact with the personnel in the confined space and who knows the
procedure and the emergency plan.
99 The staff must be aware of the risks associated with the product being handled in the confined space.
99 Control of the entry and exit of the workers must be established.
99 All personnel entering must use a lifeline, and the line must be secured outside the confined space.
Additional controls:_________________________________________________________________________________________________________

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3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), cross out the non-applicable ones and put the initials of the person assessing the risks.
12 14 16 24 Self-contained breathing apparatus for personnel entering and for the emergency plan.
12 14 16 24 Self-contained breathing apparatus for the emergency plan.
12 14 16 24 Cascade type breathing apparatus.
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4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK? YES NO
If it is in height or overhanging, also use list B25 or B30. If there are other risks due to the location, establish in section 1 of
this Checklist and specify controls in the permission in section 2.
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5. ARE THERE ADDITIONAL DANGERS DUE TO USED SUBSTANCES? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review safety data sheets of the Hazardous Substance and specify
controls in the Permit.
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Are there additional dangers due to manual handling of materials? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
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YES NO
7. Is there any other danger not listed above?
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Identify additional hazards in section 1 and specify controls in the
Excuse me.
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YES NO
8. ARE INSTRUCTIONS REQUIRED IN THE WORKPLACE?
Generally, instructions are required on the work site. If not, describe the reason.

Reason why they are not required:...........................................................................................................................................

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9. COMPLETE EVALUATION OF ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

............................................................
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Review December 2012

--------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A4
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WORK SITE VERIFICATION filled out by the Work supervisor
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10. ADDITIONAL DANGERS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or the Work Site Instructions must be noted below and referred to in your
specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
11. INSTRUCTIONS
Confirm by marking withXen the boxes on the right.
When welding inside containers, only explosion-proof equipment will be allowed. Gas cylinders will be outside of
container. The cutting equipment will be disconnected when not in use.
The rescue plans will be known to the work team, in anticipation that a worker may get trapped.
Access routes and escape routes must remain clear of obstacles, and alternative routes should be identified and communicated to staff.
All areas above and below the workplace must be inspected in order to remove objects that could fall to or
from the workplace.
24 Personnel must exit the confined space immediately if monitoring or ventilation fails.
24 Provide explosion-proof temporary lighting.
24 Forced ventilation is required when personnel are inside a confined space without self-contained breathing apparatus.
99 There should be a responsible observer in permanent contact with the personnel in the confined space who knows the
procedure and the emergency plan.
99 Staff must be aware of the risks associated with the product being handled in the confined space.
99 A control of the entry and exit of the workers will be established.
99 All personnel entering must use a lifeline, and the line must be secured outside the confined space.
Ensure that at no time are the escape routes of the workplace and the confined space obstructed.

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12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Job Site highlight the precautions in the Permit, the Risk Assessment and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Nombre
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13. CONTROLS ON SITE
All required controls have been verified and are in place, with additional hazards noted in section 10.

Job Supervisor:................................................................
Company:...........................
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Review December 2012

 PERMIT No:
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SAFETY CHECKLIST No. A5
Management of substances and materials hazardous to health, for example, radioactive sources, chemical substances
dangerous, asbestos, among others.
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HAZARD ASSESSMENT filled out by the Permit Applicant
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1. IDENTIFIED DANGERS: Add any additional dangers you consider relevant in the lines below (when required). If any danger is not
applicable, cancel it by marking (X) the corresponding number for the danger and also the numbers in controls
corresponding in sections 2, 3, and 11.

13 Chemical agents 20 Environmental Impact

17 Particles (air/water) 21 Asbestos
18 Radioactive source 22 Fiberglass / Mineral (wool) fiber
19 Flammable substance
Additional dangers: __________________________________________________
.............................................................................. ..............................................................................
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2. PERMISSION CONTROLS: The following controls must be specified in the Permission (sections 3, 4, and 5), void those that are not applicable and put the
initials of the person who evaluates the risks.
19 Portable extinguisher for class 'B'/'C' fire available on the work site.
13 18 21 22 Set barriers to prevent unauthorized personnel from passing (Critical procedure for delimited risk areas (barricades) in
PEP).
13 18 21 22 The Checklist must consider the necessary precautions for the hazardous substance, these precautions are indicated in
their respective safety data sheets.
Appropriate containers for the products or substances to be handled must be available.
Additional controls:_________________________________________________________________________________________________________

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3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), cross out the inapplicable ones and put the initials of the person assessing the risks.
13 17 18 21 22 Appropriate personal protective equipment for handling hazardous materials or substances.
13 17 21 22 Eye protection (the type of protection must be specified) ____________________________________________________.
13 17 21 22 Respiratory protection equipment (the type of protection must be specified) ________________________________________.
18 All staff must use radiation dosimeters.
4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK?
If it is at height or overhanging, also use list B25 or B30. If there are other risks due to the location, state them in section 1 of
If it is in confined spaces use checklist A4. this Checklist and specify controls in the permission in section 2.
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YES NO
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED?
Other hazardous substances. Establish in section 1 of this Checklist, review the Safety Data Sheets of the Hazardous Substance and specify
controls on the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS?IF NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. IS THERE ANY OTHER UNLISTED DANGER?
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls in the
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. ARE INSTRUCTIONS REQUIRED ON THE WORK SITE?
Generally, instructions are required on the work site. If not, describe the reason.

Reason why they are not required:...........................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE RISK ASSESSMENT OF THE ACTIVITY (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

Name:
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

SAFETY CHECKLIST No. A5
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

WORKSITE VERIFICATION filled out by the Work supervisor

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 10.
ADDITIONAL DANGERS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Work Inspection or the Site Work Instructions must be noted below and referred to in your
Specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with X in the boxes on the right.
You must notify the area Authority when you are going to start the activity.
The work will be carried out in a way that minimizes the discharge of fibers, dust, fumes, or any toxic particles into the atmosphere. The
materials must be placed in a confined area.
18 All substances will be kept in storage with restricted access and returned to their place after use.
13 Available equipment must be on hand to contain hydrocarbons or neutralize substances.
13-17 There should be a nearby eye wash station; if not, a portable station must be provided.
Accesses and escape routes must remain free of obstacles, and alternative routes must be identified and reported to personnel.
17 Erect barriers to prevent access to unauthorized personnel (Critical procedure for delineating risk areas
(barriers) in PEP).
All areas above and below the workplace must be inspected in order to remove objects that could fall onto or
from the workplace.
18 The barriers and signs for radiographic inspections must be placed at a defined position of 7.5 micro Sieverts per hour.
(0.75 µRe).
17-18-21-22 Remove non-essential personnel from adjacent areas.
18 The operating procedures of the equipment must be approved by PEMEX and by a qualified person, and must be available in
the workplaces.
18 An appropriate radiation monitor must be provided.
18 Radiation inhibited process monitors must be present in the workplace.
21 A 'habitat' must be constructed before carrying out the work.
21-22 An area for decontamination must be enabled.
20 Paint or oil drums should be in a confined area.
19 The drainage collectors in the immediate work area must be inspected and kept free of all combustible materials and protected.
with fireproof tarpaulins (wet if necessary).
20 The main drains must be checked before draining the equipment and it must be verified that the system can accumulate the
expected volumes.
18 The UV and IR detectors must be inhibited. As a general rule, the detectors should be separated from the source by at least 2.
steel walls in the horizontal or vertical plane.
18 Notify all personnel not involved in the activity of the start of the work and move them to a safe area.
21 Contaminated equipment and hazardous waste must be handled and disposed of in accordance with the applicable regulations (General Law for
Prevention and Comprehensive Management of Waste.
19 Flammable substances should not be used within one meter of hot surfaces.
21 The person responsible for the management of hazardous waste must be notified about the disposal of asbestos for their control.
18 In case of necessity, emergency actions should be noted in Section 10 of this Checklist.
18 Immediately upon exposing the source, an audible alert must be issued.
13 The mixing of chemicals should be done in well-ventilated areas.
13 No food should be consumed at the workplace.
18 For changes of location, the radioactive source must be stored in a secure container, the container must be closed and the equipment must be secured.
Emergency must be informed that the radioactive source has been stored and that the barriers can be removed.
21 Power tools (saws, drills) should not be used.
18 The log of the radioactive source must be updated.
18 The source must not be handled directly, no part of the body should be positioned between the radioactive source and the receiver.
19 The levels of the deposits must be checked before and during filling.
22 Waste must be disposed of in accordance with the safety data sheet of the hazardous substance.

12. INSTRUCTIONS AT THE WORKSITE

The Instructions on the Work Site highlight the precautions in the Permit, the assessment of Risks and Controls over these and other additional risks.
identified in section 10.

Instructions at the workplace given by:

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, with additional hazards noted in section 10.

Work Supervisor
Company:...........................

December 2012 Review

 PERMISSION No:
---------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A6
Work that affects the availability of security systems and equipment.
----------------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider below (when required). If any hazard is not
If applicable, cancel it by marking (X) the corresponding number for the hazard and also the numbers in controls.
corresponding in sections 2, 3, and 11.

47 Blocking of Gas and Fire detectors 51 Withdrawal of Passive Fire Protection

48 Blockade of the Emergency Strike 52 Explosion Mitigation Loss
49 Blocking of venting or relief systems 53 Well Control System Lockout
50 Blocking or removal of fire protection 55 Failures in the drainage system or containment dikes

Additional hazards: _____________________________________________________

.............................................................................. . .............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), cancel those that are not applicable and include the
initials of the person assessing the risks.
47 48 49 50 51 52 53 55 The system must be isolated and the isolation certificate placed in a visible location.
47 48 49 50 51 52 53 55 It is necessary to foresee the control or controls required to compensate for the temporary absence of the system or any of its elements.
You must specify the controls that will be established to compensate for the temporary lack of systems or security elements:____________________________
_______________________________________________________________________________________________________________________________
Additional controls: _____________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), write the initials of the person assessing the risks.
---------------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the location of the work? YES NO
If it is in height or suspended, also use list B25 or B30. If there are other risks due to location, establish them in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permit in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? IF NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Set in section 1 of this Checklist, review safety data sheets of the Hazardous Substance and specify
controls on the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS?YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
7. IS THERE ANY OTHER UNLISTED DANGER? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls.
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. ARE INSTRUCTIONS REQUIRED ON THE WORK SITE?
Instructions are generally required on the Work Site. If not, describe the reason.

Reason why they are not required:...................................................................................................................................--------------

-------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE RISKS OF THE ACTIVITY (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A6
---------------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Work Supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or the On-Site Instructions must be noted below and referred to in your
In case of specific controls in section 5 of the permit by the applicant, who will place their initials next to each additional hazard.
.................................................................... ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
When working in areas protected by carbon dioxide systems, ensure that no work is carried out until the
isolation should be carried out. Before removing the isolations, the mechanisms for activating them must be tested.
Access routes and escape routes must remain free of obstacles, and alternative routes must be identified and communicated to staff.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or.
from the workplace.
The impact on the availability of the system and security equipment must be minimized to the shortest possible time.
49 Confirm that the remaining drainage capacity is sufficient for the process. If the remaining capacity is not adequate, contact the
control room.
50 Alternative fire protection systems or equipment must be installed and tested.
53 Where the work is of a lesser nature or of short duration, the approval of the operator of the control systems is required.
well.
53 The well and the Subsurface Safety Valve (SSV) must be closed before starting the work.
55 Alternative drains or containment means must be operating where necessary.
55 Temporary drains should not be located in the same area where there are operations involving fire, or with gas and fire detectors.
48 An operator in the control room must monitor the Emergency Shutdown (ESD) system that is inhibited, the work equipment must
be attentive to the required actions to close the emergency valve and they must communicate with each other.
Only one section of the system should be inhibited at a time; if this is not possible, alternative arrangements should be made.
51 The time during which the protection is inactive must be minimal. If there are prolonged periods of inactivity, measures must be implemented.
necessary on-site or in the installation to reduce risks, (for example, limitation of hot work in the area, etc.)
---------------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS AT THE WORKPLACE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Name
---------------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, with additional hazards noted in section 10.

Job Supervisor
Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------------
 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A7
Electrical work that includes the opening of junction boxes, cabinets, panels connected in hazardous areas,
(circuits not intrinsically safe).
---------------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add additional hazards you consider necessary in the lines below (when required). If any hazard is not
If applicable, cancel by marking (X) the corresponding number for the danger and also the numbers in controls.
corresponding in sections 2, 3, and 11.

5 Electric Spark 8 Energized electrical conductors (fixed)

Additional dangers: __________________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMIT CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), annul the inapplicable ones and include the
initials of the person assessing the risks.
8 The equipment will be isolated and grounded in accordance with electrical safety rules.
5 Portable fire extinguisher for class 'B'/'C' fire available at the worksite.
5 Verification tests will be conducted for hydrocarbon gas (specify the frequency in the permit).
8 Set up barriers to prevent access to unauthorized personnel (Critical procedure for delimiting risk areas (barricades) in PEP).
5 Continuous monitoring must be conducted for the detection of hydrocarbon-derived gases.
8 Access Limitation, Permit for electrical work, and Penalty for required testing (invalidate inapplicable documents).
Additional controls: ________________________________________________________________________________________________________
No text provided for translation.
---------------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), cross out the inapplicable ones and put the initials of the person assessing the risks.
8 Rubber gloves suitable for the electrical voltage required to perform the work.
---------------------------------------------------------------------------------------------------------------------------------------------------------
4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK? YES NO
If it is at height or overhanging, also use list B25 or B30. If there are other risks due to the location, state them in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review Safety Data Sheets of the Hazardous Substance, and specify controls.
in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. Is there any other danger not listed above?
Examine the hazards in sections 1, 4, 5, and 6, and any other relevant information. Identify additional hazards in section 1 and specify controls in the
Excuse me.
-------------------------------------------------------------------------------------------------------------------------------------------------------
IF NO
8. Are instructions required at the workplace?
Generally, instructions are required at the Work Site. If not, please describe the reason.

Reason why they are not required:...................................................................................................................................

9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).

The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

...............................................................
-------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A7
--------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKSITE
Any additional hazards identified in the Work Site Inspection or the Work Site Instructions must be noted below and referred to in your case.
Specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
-------------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with X in the boxes on the right.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
Access routes and escape routes must remain free of obstacles, and alternative routes must be identified and informed to the staff.
5 The cables will be checked by the electrical manager.
8 Isolation label available at the workplace.
8 Insulating mats must be used at electrical terminals.
8 Covers or lids must be placed in the workplace if it is going to be left, even for short absences.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Name
---------------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, with additional hazards noted in section 10.

Supervisor del trabajo

---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
------------------------------------------------------------------------------------------------------------------------------------------------------------
SECURITY CHECKLIST No. A8
Title: Jobs that involve intervening with equipment, pipes, and systems that contain hydrocarbons or hazardous fluids,
except for lines and accessories for instrumentation.
------------------------------------------------------------------------------------------------------------------------------------------------------------
-
HAZARD ASSESSMENT filled out by the Permit Applicant

1. IDENTIFIED DANGERS: Add additional dangers that you consider in the lines below (when necessary). If any danger is not
applicable, cancel it by marking (X) the corresponding number for the hazard and also the numbers in controls
corresponding in sections 2, 3, and 11.

12 Release of hydrocarbons 27 Cutting or abrasive object

13 Chemical agents 35 Possibility of getting trapped
14 Toxic gas 44 Failure of the lifting equipment
20 Environmental impact 46 Accumulated energy discharge (mechanical / pressure)
Additional dangers: _________________________________________________ ______________________________________________________
.............................................................................. ..............................................................................
------------------------------------------------------------------------------------------------------------------------------------------------------------
-
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), eliminate those that are not applicable and include the
initials of the person assessing the risks.
14 Breathing equipment available for all team members.
14 Gas tests (oxygen and/or toxic gases, specify which ones) must be carried out ____________________________________________.
12 13 14 44 Place barriers to prevent access to unauthorized personnel (Critical procedure for delineating risk areas (barriers) in
PEP.
12 14 46 The system must be isolated and the isolation certificate placed in a visible location.
12 Continuous monitoring must be carried out for the detection of gases derived from hydrocarbons.
14 Constant monitoring of toxic gas must be done during the execution of the work.
13 The Checklist should take into account the necessary precautions for the hazardous substance, these precautions are indicated in
their respective safety data sheets.
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), annul the non-applicable ones and put the initials of the person evaluating the risks.
13 Appropriate personal protective equipment for handling hazardous substances.
12 13 14 Self-contained breathing apparatus for incoming personnel and for the emergency plan.
12 13 14 Self-contained breathing apparatus for the emergency plan.
12 13 14 Cascade type breathing apparatus.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the location of the work? YES NO
If it is at height or suspended, also use list B25 or B30. If there are other risks due to the location, specify in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls on the permit in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass, Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review the Safety Data Sheets for the Hazardous Substance and specify controls.
in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional hazards due to manual handling of materials? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. IS THERE ANY OTHER UNLISTED DANGER?
Examine the hazards in sections 1, 4, 5, and 6, and any other relevant information. Identify additional hazards in section 1 and specify controls in the.
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. Are instructions required at the workplace?
Generally, instructions are required at the workplace. If not, please describe the reason.

Reason why they do not equate:

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE RISK ASSESSMENT OF THE ACTIVITY (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all the appropriate controls are in place.

Nombre

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A8
---------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified during the Site Inspection or the Site Instructions must be noted below and referred to in your case.
Specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
Access and escape routes must remain free of obstacles and alternative routes must be identified and communicated to the
personal.
The manometer for checking the depressurization must be of the appropriate range and calibrated to ensure that the pressure is
correctly drained.
46 To secure the springs, an approved tool must be used to compress or tension the springs.
13 There must be equipment available to contain hydrocarbons or neutralize substances.
13 There should be a nearby eye wash station; if not, a portable station should be provided.
14 The medical staff must be informed of the work to be done.
12 Ensure that relief downloads and discharges do not pose risks.
15 If the smoke and dust extraction system is required, it must be included to remove them; the work must be suspended if it fails.
team.
20 Paint or oil drums must be in a confined area.
20 The main drains must be checked before draining the equipment and it must be verified that the system can accumulate the
expected volumes.
12 Special care must be taken to avoid trapped hydrocarbon points and 'dead legs' or low points.
27 Sharp edges must be removed or protected with soft material where work is being done.
46 The asparagus must be released gradually and not removed completely until it is verified that there is no tension in the straps.
44 Lifting maneuvers must be planned and visually inspected before being carried out.
13-14 No food should be consumed in the workplace.
44 The equipment and process or auxiliary lines should not be used to install rigging, scaffolding, or support loads.
44 The strobe lights or slings must be placed according to the procedure for lifting or hoisting loads.
14 The work must be carried out by a minimum of 2 people.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS ON THE WORKSITE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Name:................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

..........................................................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMISSION No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A9
Title: Lifting operations of equipment and materials near pressurized hydrocarbon systems, facilities, and/or
personnel unrelated to the maneuvers.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider in the lines below (when required). If any hazard is not
Applicable, cancel it by crossing out (X) the corresponding number for the hazard as well as the numbers in controls.
corresponding in sections 2, 3, and 11.

23 Inertia of objects in general 44 Failure of the lifting equipment

30 Heavy or difficult-to-grasp object 93 Communication failure
34 Poor visibility / Lighting
Additional hazards: _________________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permission (sections 3, 4, and 5), annul the non-applicable ones and put the
initials of the person who evaluates the risks.
23 30 44 Put up barriers to prevent unauthorized access (Critical procedure for delimiting risk areas (barricades) in
PEP).
93 There must be communication equipment between the maneuvering assistant and the operator.
34 There should be a person who guides the operator during the maneuver; this person must be distinguished from the others by their...
clothing.
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), put the initials of the one who evaluates the risks.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the location of the work? YES NO
If it is at height or overhanging, also use list B25 or B30. If there are other risks due to the location, state them in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to substances used? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Specify in section 1 of this Checklist, review Safety Data Sheets for the Hazardous Substance and specify
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional hazards due to manual handling of materials? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
7. Is there any other danger not listed above? YES NO
Examine the hazards in sections 1, 4, 5, and 6, and any other relevant information. Establish additional hazards in section 1 and specify controls.
Excuse me.
---------------------------------------------------------------------------------------------------------------------------------------------------
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Instructions are generally REQUIRED at the Work Site. If not, please describe the reason.

Reason why they are not required: ......................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

Name
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 ---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. A9
---------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL DANGERS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or Worksite Instructions must be noted below and referred to in
In your case, specific controls in section 5 of the permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
All areas above and below the workplace must be inspected in order to eliminate objects that could fall towards or
from the workplace.
Accesses and escape routes must remain free of obstacles and alternative routes must be identified and communicated to staff.
34 A person who is familiar with the activity and the work site will be designated to guide the operator during the maneuver, this person
she must be differentiated from the others by her clothing, and she will be the only one to signal the operator in order to avoid confusion.
The cables and hoses must be of a minimum length, free of temporary joints, not twisted, secured at intervals.
Regular and kept away from stairs, wet areas, and corridors. They should be protected where it is not possible to cover them.
Lifting operations will not be performed on unprotected high-pressure pipes.
93 There must be communication equipment between the maneuvering assistant and the operator.
23 The identification of lines must be fixed or with suspended objects.
44 Lifting maneuvers must be planned and visually inspected before being carried out.
44 The equipment and process or auxiliary lines should not be used to install rigging, scaffolding, or support loads.
44 The strobe lights or slings must be placed according to the lifting manual of the specific equipment.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Worksite highlight the precautions in the Permit, the Risk Assessment and Controls over these and other additional risks.
identified in section 10.

Instructions at the workplace given by:

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards have been noted in section 10.

Job Supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A10
Title: Testing and start-up activities of equipment handling hydrocarbons or that may pose a threat to the
Personnel security.
----------------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider in the lines below (when required). If any hazard is not
If applicable, cancel it by marking (X) the corresponding danger number and also the numbers in controls.
corresponding in sections 2, 3 and 11.

12 Hydrocarbon Release 36 Power supply failure.

17 Particles (air/water) 46 Accumulated energy discharge (mechanical / pressure)
26 Stored Electric Charge 73 Overpressure
28 Projectiles
Additional hazards: __________________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), cancel the inapplicable ones and put the
initials of the person who assesses the risks.
12:46 Portable fire extinguisher for class 'B'/'C' fire available at the workplace.
12 46 Have a pressurized fire hose dedicated exclusively for this work.
12 73 Verification tests for hydrocarbon gas will be carried out (specify frequency in the permit).
36 12 17 28 Place barriers to prevent unauthorized personnel from entering (Critical procedure for delineating risk areas (barricades) in
PEP).
73 46
12 17 28 46 A fire safety assistant must be appointed.
46
26 17 28 46 The medical staff must be informed about the work to be done.
Additional controls: _________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), cross out the non-applicable ones and put the initials of the person evaluating the risks.
17 28 46 Eye protection (the type of protection must be specified) _____________________________________________________.
12 Respiratory protection equipment (the type of protection must be specified) ________________________________________.
---------------------------------------------------------------------------------------------------------------------------------------------------------
4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK? YES NO
If it is at height or suspended, also use list B25 or B30. If there are other risks due to the location, establish in section 1 of
If it is in confined spaces use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO USED SUBSTANCES? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass, or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review hazard substance data sheets and specify.
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to manual handling of materials? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
7. Is there any other danger not listed above? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls.
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------------
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Generally, instructions are indeed required on the work site. If not, describe the reason.

Reason why they are not required:...................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPREHENSIVE RISK ASSESSMENT OF THE ACTIVITY (APPLICANT).
The assessment of all hazardous conditions has been completed, and it has been verified that all appropriate controls are in place.

................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

--------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. Al0
---------------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL DANGERS IDENTIFIED IN THE WORKSITE
Any additional hazards identified during the Site Inspection or the Site Instructions must be noted below and referenced in your
In the case of Specific Controls in section 5 of the Permit by the applicant, who will place his initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
You must notify the Authority of the area when you are going to start the activity.
26-36 The equipment must be isolated and grounded according to electrical safety rules.
The medical staff must be informed of the work to be done.
12-17-28 There should be a nearby eyewash station; if not, a portable station should be provided.
12 Rescue case or breathing apparatus available for all team members.
12-17 Oil spills and other fluids must be collected and/or cleaned immediately.
The flood system must be operational and the way to operate it should be known and understood by the entire work team.
Access routes and escape routes must remain free of obstacles, and alternative routes must be identified and communicated to the staff.
26-12-73-46 Only qualified and competent individuals will carry out the tasks, the operation of the equipment, and the handling of the substances involved.
The drainage collectors in the immediate work area must be checked and kept free of all combustible materials and protected.
with fireproof tarps (wet if necessary).
Set up barriers to prevent unauthorized personnel from entering (Critical procedure for delimiting risk areas)
(barricades) in PEP).
The supervisor must review the work area before starting activities and during their execution.
26-12-73-46 The operating procedures of the equipment must be approved by PEMEX and by a qualified person, and must be available at
the workplaces.
All areas above and below the workplace must be inspected in order to remove objects that could fall to or.
from the workplace.
12-17-28 Notify all personnel not involved in the activity about the start of the work and remove them to a safe area.
12 There must be available equipment to contain hydrocarbons or neutralize substances.
73-46 When the system is emptied after testing, the possibility of a vacuum and its effects must be taken into account.
The depressurization index will be controlled to ensure that the vessel receives the proper adjustment when drained.
Food should not be consumed at the workplace.

--------------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls over these and other additional risks.
identified in section 10.

Instructions at the workplace given by:

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. A11
Diving Operations. The specific procedure must be included for its authorization.
--------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD EVALUATION filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider in the lines below (when required). If any hazard
not applicable, cancel it by crossing out (X) the number corresponding to the danger and also the numbers in
corresponding controls in sections 2, 3, and 11.

24 Air supply failure 63 Falling Objects

35 Possibility of getting trapped 93 Failure in communication
62 Severe / adverse weather condition
Additional dangers: __________________________________________________ ________________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), invalidate the non-applicable ones and
put the initials of the person who evaluates the risks.
24 A trained diving supervisor must be appointed.
24 62 A "habitat" must be placed where necessary before carrying out the work.
35 63 All areas above and below the workplace must be inspected to minimize the likelihood of falling objects.
to or from the workplace.
24 The diving supervisor must verify that the Air Quality is adequate.
24 The diving supervisor must verify that the gas mixture is appropriate for the depth of the dive.
24 The diving supervisor must verify that the air supply equipment is in operational condition.
The PEMEX supervisor must verify that the procedure meets all the work conditions.
The PEMEX supervisor must verify that the personnel performing the activity is accredited.
The PEMEX supervisor is responsible for compliance with the specific procedure for the activity.
93 A redundant communication system must be established.
93 If communication between the diver and the supervisor fails, the activity must be suspended.
Additional controls: _________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), put the initials of the person evaluating the risks.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the location of the work? IF NO
Disable in the vicinity of water intakes or suction points. If there are other risks due to the location, establish in the
suction, if it is from the fire protection network use Checklist A6. section 1 of this Checklist and specify controls in the
If it is in confined spaces use Checklist A4. permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to substances used? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass, or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review hazardous substance data sheets and specify
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional hazards due to manual handling of materials? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
7. ARE THERE ANY OTHER UNLISTED DANGERS? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls in the
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------
8. ARE INSTRUCTIONS REQUIRED ON THE WORK SITE? YES NO
Generally, instructions are required on the work site. If not, describe the reason.

Reason why they are not required:

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE RISK ASSESSMENT OF THE ACTIVITY (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------

Revision December 2012

--------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. A11
--------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKSITE
Any additional hazards identified in the Work Site Inspection or the Work Site Instructions must be noted below and referred to in your
specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.
---------------------------------------------------------------------------------------------------------------------------------------------------

11. INSTRUCTIONS
Confirm by marking with X in the boxes on the right.
You must notify the Authority of the area when you are going to start the activity.
The dynamic positioning system of the vessel has been tested to support diving activities.
In addition to the normal barriers and signs, signals will be deployed at the entrances of all access points and/or corridors and at the controls of
the pumps and in the valves of the ducts (open/closed indications).
The diving supervisor checked that the critical equipment is in operational condition (Compressor, air bank, connections, Racks)
air cylinders for gas mixtures, communication systems, diving equipment, hyperbaric chamber, among others.
35 If the platform's condition changes from normal to alert condition, the diver and the bell will be recovered according to the Plan of
Response to Boat Emergency.
93 Alternative communication measures must be available and tested. Alternative lines of command and control must agree.
above all, in case they fail.
63 Avoid the risk of falling objects by securing tools and equipment.
62 Work outside must be suspended when the wind exceeds 55 km/h.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS AT THE WORKPLACE
The Instructions at the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls over these and other additional risks.
identified in section 10.

Instructions at the workplace given by:

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional risks above 10 have been noted.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B20
Sandblasting
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider necessary in the lines below (when required). If any hazard
not applicable, cancel it by crossing out (X) the corresponding number for the danger and also the numbers in
corresponding controls in sections 2, 3 and 11.

4 Mechanical spark 25 High-pressure jet

7 Spark of static electricity 29 Risk of slipping
16 Octopus 33 Noise
17 Particles (air/water) 40 Connection failure / pressurized hose
Additional hazards: _____________________________________________ __________________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), annul those that are not applicable and
put the initials of the person who evaluates the risks.
4 7 Verification tests of hydrocarbon gas will be conducted (specify frequency in the permit).
4 7 17 29 Place barriers to prevent access to unauthorized personnel (Critical procedure for the delimitation of risk areas)
(barricades) in PEP).
4 7 Continuous monitoring must be conducted for the detection of gases derived from hydrocarbons.
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), cross out the non-applicable ones and put the initials of the evaluator.
risks.
17 Eye protection (the type of protection should be specified) ____________________________________________________.
33 Hearing protection.
16 17 Respiratory protection equipment (the type of protection must be specified) _______________________________________.
---------------------------------------------------------------------------------------------------------------------------------------------------
4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK? YES NO
If it is at height or suspended, also use list B25 or B30. If there are other risks due to the location, state them in section 1 of
If it is in confined spaces use checklist A4. this Checklist and specify controls in the permission in section 2.
--------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review the data sheets of the Hazardous Substance and specify
controls on the permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional hazards due to manual handling of materials? YES NO
For example, are there heavy or long objects to be handled? Set this in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
7. Is there any other danger not listed above? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Generally, instructions are required on the job site. If not, please describe the reason.

Reason why they are not required:...................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

....................................................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B20
---------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Work Supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Job Site Inspection or the Job Site Instructions must be noted below and referred to in your
in case of Specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with X the boxes on the right.
Containers for welding rods and used material must be used.
Access and escape routes must remain free of obstacles, and alternative routes should be identified and communicated to staff.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
Rubber gloves and boots with instep protection, face shield, and suitable clothing included in the work gear will be used.
Collect the sand generated during the operation and do not allow accumulation.
The sandblasting compressor must stop if it does not have an emergency stop system.
The security alarm buttons must be functional and their operation will be verified. Only closed circuit should be.
allowed in hazardous areas.
7 The equipment, including any extensions such as poles and/or scaffolding, must be electrically grounded. The hoses
They are electrical conductors.
40 The hose couplings must be secured at all points.
17 There should be a nearby eyewash station; if not, a portable station must be provided.
17 Place barriers to prevent unauthorized personnel from entering (Critical procedure for delineating risk areas)
(barricades) in PEP).
16 If the smoke and dust extraction system is required, it must be included to remove them, and work must be suspended if the equipment fails.
25 The delicate equipment must be protected.
33 An alternative warning method should be adapted where audible alarms cannot be heard.
Cables and hoses must be of a minimum length, free of temporary joints, not twisted, secured at intervals.
Regular and kept away from stairs, damp areas, and hallways. They should be protected where it is not possible to cover them.
25 The nozzles and guns should not be removed when the plant is operating.
40 Hoses should not be twisted during operation and should not be pressured when not in use.
25 The engine exhausts should not be directed toward personnel access even if they are turned off, and no one will be allowed to pass.
in front.
16 Food should not be consumed in the workplace.
4 The workpieces and/or tools must be cooled with water when necessary.
25 The work must be carried out by a minimum of 2 people.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS ON THE WORKSITE
The Instructions on the Work Site highlight the precautions on the Permit, the Risk Assessment, and Controls related to these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, with additional hazards noted in section 10.

Job Supervisor
Company:...........................
--------------------------------------------------------------------------------------------------------------------------------------------------

Revision December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B21
Removal of paint or burrs in process installations, using manual, electric, or
pneumatics, such as reamers, bristles, or rollers.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider necessary in the lines below (when required). If any hazard
not applicable, cancel it by crossing out (X) the corresponding number for the hazard and also the numbers in
corresponding controls in sections 2, 3, and 11.

4 Mechanical spark 33 Noise

7 Spark of static electricity 37 Vibration
9 Heavy-duty energized electrical conductors 40 Connection Failure / Pressurized Hose
16 Octopus 43 Power Cable Failure
17 Particles (air/water) 45 Rotating machinery or tools
Additional dangers: ______________________________________________ ____________________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMIT CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), cancel the inapplicable ones and
put the initials of the person assessing the risks.
4 7 Verification tests of hydrocarbon gas will be carried out (specify frequency in the permit).
4 7 17 40 Place barriers to prevent access to unauthorized personnel (Critical procedure for delineating risk areas)
(barricades) in PEP).
4 7 Continuous monitoring must be carried out for the detection of gases derived from hydrocarbons.
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), revoke the inapplicable ones and put the initials of the person evaluating the risks.
17 Eye protection (the type of protection must be specified) ____________________________________________________.
33 Hearing protection.
16 17 Respiratory protection equipment (the type of protection must be specified) ______________________________________.
---------------------------------------------------------------------------------------------------------------------------------------------------
4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK? YES NO
If it is at height or suspended, also use list B25 or B30. If there are other risks due to the location, specify in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Specify in section 1 of this Checklist, review the Safety Data Sheets of the Hazardous Substance and specify
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS?
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. IS THERE ANY OTHER UNLISTED DANGER?
Examine the hazards in sections 1, 4, 5, and 6, as well as any other relevant information. Identify additional hazards in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE?
Instructions are generally required at the Work Site. If not, please describe the reason.

Reason why they are not required:...................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE RISKS OF THE ACTIVITY (APPLICANT).
The evaluation of all hazardous conditions has been completed, and it has been verified that all the appropriate controls are in place.

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B21
---------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL DANGERS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Job Site Inspection or Job Site Instructions must be noted below and referred to in your
Specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
Accesses and escape routes must remain free of obstacles and alternative routes must be identified and communicated to the staff.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
45 The machinery must be checked when it begins to work.
7 The equipment, including any extensions such as poles and/or scaffolding, must be electrically grounded. The hoses
they are electrical conductors.
9-43 All electrical equipment, tools, and non-certified explosion-proof testing equipment will be verified and labeled by the
electrical manager.
9 The equipment must be checked.
45 Rotating arrows and rotating discs must have protective guards.
40 Hose couplings must be secured at all points.
17 There should be a nearby eye wash station; if not, a portable station should be provided.
9-43 Grounding devices must be installed and properly grounded.
17 Place barriers to prevent unauthorized personnel from passing (Critical procedure for delimiting risk areas)
(barricades) in PEP).
16 If a smoke and dust extraction system is required, it must be included to remove them; work must be suspended if the equipment fails.
9 The Portable team must be powered by supplies that are connected to a protected system.
33 An alternative warning method must be adapted where audible alarms cannot be heard.
43 The cables and hoses must be of a minimum length, free from temporary joints, not twisted, secured at intervals.
Regular and kept away from stairs, wet areas, and corridors. They should be protected where it is not possible to cover them.
43 Electric cables should be used extended to avoid overheating.
40 Hoses should not be twisted during operation and should not be under pressure when not in use.
16 No food should be consumed in the workplace.
45 The equipment must be de-energized and the hoses depressurized when not in use and before carrying out any
maintenance.
4 Workpieces and/or tools must be cooled with water when necessary.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS AT THE WORKSITE
The Instructions at the Workplace highlight the precautions in the Permit, the Risk Assessment, and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Revision December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B22
Title: Use of hydraulic, pneumatic, or manual tools for cutting metal, demolishing concrete, for splintering or
chop down in risky areas.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED DANGERS: Add any additional dangers you consider necessary in the lines below (when required). If any danger
not applicable, cancel it by crossing out (X) the corresponding danger number and also the numbers in
corresponding controls in sections 2, 3 and 11.

4 Mechanical spark 45 Rotary machine or tools

17 Particles (air/water) 40 Connection Failure / Pressurized Hose
33 Noise
Additional dangers: _____________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMIT CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), cancel those that are not applicable.
put the initials of the person who assesses the risks.
4 Verification tests for hydrocarbon gas will be carried out (specify frequency in the permit).
4 17 40 Place barriers to prevent access to unauthorized personnel (Critical procedure for delineating risk areas)
(barricades) in PEP).
4 Continuous monitoring must be conducted for the detection of gases derived from hydrocarbons.
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), cancel the inapplicable ones and put the initials of the person assessing the risks.
17 Eye protection (the type of protection must be specified) __________________________________________________.
33 Hearing protection.
17 Respiratory protection equipment (the type of protection must be specified) _____________________________________.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the location of the work? YES NO
If it is elevated or cantilevered, also use list B25 or B30. If there are other risks due to the location, state them in section 1 of
If it is in confined spaces use checklist A4. this Checklist and specify controls in the permit in section 2.
--------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? IF NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review hazardous substance data sheets and specify
controls in the Permission.
--------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. IS THERE ANY OTHER DANGER NOT LISTED ABOVE?
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls in the.
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE?
Generally, YES, instructions are required at the Work Site. If not, describe the reason.

Reason why they are not required:...................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

--------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B22
---------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------

10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE

Any additional hazards identified in the Work Site Inspection or the Work Site Instructions must be noted below and referred to in your
In the case of specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
Access points and escape routes must remain clear of obstacles, and alternative routes should be identified and communicated to staff.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
The cables and hoses must be of a minimum length, free of temporary joints, not twisted, secured at intervals.
regular and kept away from stairs, damp areas, and hallways. They should be protected where it is not possible to cover them.
For the air-operated grinder, a standard ISl03 fixed-length air hose with a Verified label will be used.
45 The machinery must be checked when it starts working.
45 Rotating arrows and rotating discs must have protective guards.
40 The hose connections must be secured at all points.
There should be a nearby eye wash station; if not, a portable station should be provided.
33 An alternative warning method should be adapted where audible alarms cannot be heard.
40 Hoses should not be twisted during operation and must be depressurized when not in use.
45 The equipment must be de-energized and the hoses depressurized when not in use and before carrying out any
maintenance.
4 Workpieces and/or tools must be cooled with water when necessary.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS ON THE WORK SITE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Supervisor del trabajo

Company:...........................
--------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMISSIONNo
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B23
Temporary Use of Internal Combustion Engines in Hazardous Areas.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add additional hazards you consider necessary in the lines below (when required). If any hazard
not applicable, cancel it by crossing out (X) the corresponding number for the danger and also the numbers in
corresponding controls in sections 2, 3, and 11.

2 Hot welding slag / Fiery spatter 19 Flammable Substance

5 Electric Spark 33 Noise
7 Spark of static electricity 45 Rotary machinery or tools
Additional hazards: ______________________________________________
............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMIT CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), nullify the not applicable ones and
put the initials of the one who evaluates the risks.
The internal combustion engine must be located in areas with a lower risk of hydrocarbon presence.
2 The exhausts must have spark arresters.
2 The exits must lead to safe areas
5 19 Portable extinguisher for fire class 'B'/'C' available at the workplace.
5 7 Verification tests for hydrocarbon gas will be carried out (specify the frequency in the permit).
45 Place barriers to prevent access to unauthorized personnel (Critical procedure for delimiting risk areas)
(barricades) in PEP).
7 The equipment must be grounded according to regulations.
5 7 Continuous monitoring must be carried out for the detection of gases derived from hydrocarbons.
Additional controls: _________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), strike out the non-applicable ones and put the initials of the person evaluating the risks.
33 Hearing protection.
---------------------------------------------------------------------------------------------------------------------------------------------------
4. Are there additional dangers due to the location of the work? YES NO
If it is at height or suspended, also use list B25 or B30. If there are other risks due to the location, establish in section 1 of
If it is in confined spaces use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass, or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review safety data sheets for the Hazardous Substance and specify.
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. IS THERE ANY OTHER UNLISTED DANGER?
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in 1 and specify controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. ARE INSTRUCTIONS REQUIRED ON THE WORK SITE?
Generally, instructions are required at the work site. If not, describe the reason.

Reason why they are not required:

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

...........................................................
---------------------------------------------------------------------------------------------------------------------------------------------------

Revision December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. B23
---------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Job supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------

10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE

Any additional hazards identified during the Job Site Inspection or the Job Site Instructions must be noted below and referred to in your
In the case of Specific Controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with X the boxes on the right.
All areas above and below the workplace must be inspected in order to remove objects that could fall to or
from the workplace.
Access routes and escape routes must remain free of obstacles, and alternative routes must be identified and communicated to personnel.
The following documents will be available with a copy of the permit on the work site.
a) Certification in zone 2 of the plant for diesel machinery.
b) Cert. with team components, flame arresters
c) Data in the workplace inspection lists
The location of the diesel machinery will be according to the following classification:
a) zone 1, not permitted.
b) zone 2, avoid as much as possible.
45 The machinery must be inspected when it starts working.
7 The equipment, including any extensions such as poles and/or scaffolding, must be electrically grounded, the hoses are
electric conductors.
5 The cables will be checked by the electrical supervisor.
45 Rotating arrows and rotating discs must have protective guards.
5 The Portable team must draw power from supplies connected to a protected system.
19 The drainage collectors in the immediate work area must be checked and kept clean of all combustible materials and protected.
with fireproof tarps (wet if necessary).
33 An alternative warning method should be adapted where audible alarms cannot be heard.
The cables and hoses must be of a minimum length, free from temporary splices, not twisted, secured at intervals.
regular and kept away from stairs, damp areas, and hallways. They should be protected where it is not possible to cover them.
19 Flammable substances should not be used within one meter of hot surfaces.
19 Tank levels must be checked before and during filling.
45 The equipment must be de-energized and the hoses de-pressurized when not in use and before carrying out any
maintenance.
---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Worksite highlight the precautions in the Permit, the Risk Assessment, and Controls over these and other additional hazards.
identified in section 10.

Instructions on the job site given by:

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B24
Use of non-IS (non-intrinsically safe) equipment in hazardous areas, such as electric drills, phones
cell phones, etc.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMIT CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), nullify the inapplicable ones and
put the initials of the person who assesses the risks.

No text provided
Electric
forSpark
translation.
9 Energized heavy-duty electrical conductors
43 Electric Cable Failure
Additional dangers: _____________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), nullify the inapplicable ones and
put the initials of the person evaluating the risks.
5 Portable fire extinguisher for class 'B'/'C' fire available on the work site.
5 Verification tests for hydrocarbon gas will be conducted (specify frequency in the permit).
5 Continuous monitoring for the detection of hydrocarbon-derived gases must be carried out.
Additional controls:_________________________________________________________________________________________________________
_______________________________________________________________________________________________________
---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), enter the initials of the person evaluating the risks.
---------------------------------------------------------------------------------------------------------------------------------------------------
4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK? YES NO
If it is elevated or protruding, also use list B25 or B30. If there are other risks due to the location, establish them in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass, or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review the Safety Data Sheets of the Hazardous Substance and specify
controls on the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to manual handling of materials? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. IS THERE ANY OTHER DANGER NOT LISTED ABOVE?
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Identify additional hazards in 1 and specify controls in the
Excuse me.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE?
Generally, instructions are required at the work site. If not, describe the reason.

Reason why they are not required:...................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE ASSESSMENT OF THE ACTIVITY RISKS (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

Name
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B24
---------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Job Supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL DANGERS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or the Site Instructions must be noted below and referred to in your
specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------

11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or.
from the workplace.
Accesses and escape routes must remain clear of obstacles and alternative routes should be identified and reported to personnel.
9-43 All electrical equipment, tools, and unapproved explosion-proof testing equipment will be verified and labeled by the
electric manager.
5-9 The cables will be checked by the electrical supervisor.
5-43 Ground fault devices must be properly grounded.
5-9 The portable team must be powered by supplies that are connected to a protected system.
43 The cables and hoses must be of a minimum length, free of temporary joints, not twisted, secured at intervals.
Regular and kept away from stairs, wet areas, and corridors. They must be protected where it is not possible to cover them.
43 Electric cables should be used extended to avoid overheating.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS AT THE WORKSITE
The Instructions on the Work Site highlight the precautions in the Permit, the risk assessment, and controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Job Supervisor
Company:...........................
-----------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B25
Jobs with a risk of falling into water.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider necessary in the lines below (when required). If any hazard
not applicable, cancel it by crossing out (X) the corresponding danger number and also the numbers in
corresponding controls in sections 2, 3, and 11.
31 Height
32 The sea
62 Severe / adverse weather condition
Additional dangers: ______________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), nullify the non-applicable ones and
put the initials of the person evaluating the risks.
31 For offshore platform work at a certain height, a competent lookout must be present in contact with the personnel in charge.
from the control room operations.
31 Review the system or equipment before being used for work at height, according to the manufacturer's instructions,
regarding possible wear, damage, deterioration, malfunctioning or other anomalies.
31 Place barriers to prevent unauthorized personnel from entering (Critical procedure for delimiting risk areas)
(barricades) in PEP).
32 The location of life vests and life rings must be known by all personnel carrying out the work.
---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), cross out the not applicable and put the initials of the person evaluating the risks.
32 Life jackets when working on the side, underneath the installation, or in the peripheral area of the deck.
31 Lifeline.
31 Safety harness.
31 Helmets with chin straps.
31 Personal protection systems to interrupt falls from height.
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the location of the work? YES NO
If it is elevated or overhanging, also use list B30. If there are other risks due to the location, establish in section 1 of
If it is in confined spaces, use the A4 checklist. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO THE SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review the Safety Data Sheets of the Hazardous Substance and specify
controls in the Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. IS THERE ANY OTHER DANGER NOT LISTED ABOVE?
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in 1 and specify controls.
Excuse me.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE?
Generally YES, instructions are required at the Work Site. If not, please describe the reason.

Reason why they are not required:...................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE RISK ASSESSMENT OF THE ACTIVITY (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B25
---------------------------------------------------------------------------------------------------------------------------------------------------
CHECK THE WORK SITE filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL DANGERS IDENTIFIED AT THE WORK SITE
Any additional hazards identified during the Site Inspection or the Job Site Instructions must be noted below and referred to in your
In the case of Specific Controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with X the boxes on the right.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
Accesses and escape routes must remain free of obstacles, and alternative routes must be identified and communicated to the staff.
You must notify the Authority of the area when you are going to start the activity.
Before any operation beneath a facility, confirmation will be obtained from the production departments and/or
drilling so that all discharges in the area are isolated and the isolation certificates are attached.
The following documentation must be available and understood by the work team: rescue plans in case of emergency,
training certificate for operators, insurance certificate for people descending with ropes, and equipment log.
31 The personnel must use a safety cable attached to 2 separate points of the anchorage in the main structure.
31 To descend, a backup line is required and both ropes must have 2 separate anchor points attached to the structure.
principal
31 Supervise at all times that the personal fall protection system is used according to the instructions established in the
manufacturer.
31 Use a personal protection system to prevent falls from height when working at height.
31 Check the system or equipment before being used in the execution of work at height, according to the manufacturer's instructions.
regarding possible wear, damage, deterioration, malfunction or other anomalies.
31 Visually inspect, prior to its use, the area where the ladder will be employed, in order to ensure that it is not
There are risk conditions when using a step ladder.
31 Immediately remove from service any step ladders that have defects that may affect their safe use and are marked with the
Legend: "Dangerous. Do not use." or something similar, before proceeding to its repair, disposal, or destruction.
31 The equipment and process or auxiliary lines should not be used to install rigging, scaffolding, or support loads.
31-62 Work at height must be suspended when the wind exceeds 45 km/h, if there is a risk of a blackout or electrical storm.
31 The work must be carried out by a minimum of 2 people.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS AT THE WORK SITE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been checked and are in place, and additional hazards have been noted in section 10.

............................................................
Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMISSION No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B26
Use of high-pressure water jets, Including wet sandblasting.
-------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add additional hazards you consider relevant in the lines below (when necessary). If any hazard
not applicable, cancel it by crossing out (X) the corresponding danger number and also the numbers in
corresponding controls in sections 2, 3, and 11.

7 Spark of static electricity 33 Noise

17 Particles (air/water) 37 Vibration
25 High pressure jet 40 Connection Failure / Pressurized Hose
29 Risk of slipping
Additional hazards: ______________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMIT CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), override the non-applicable ones.
put the initials of the person evaluating the risks.
7 Verification tests for hydrocarbon gas will be conducted (specify frequency in the permit).
7 17 29 25 40 Put up barriers to prevent unauthorized personnel from passing (Critical procedure for delineating risk areas)
(barricades) in PEP).
7 Continuous monitoring must be conducted for the detection of gases derived from hydrocarbons.
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), cancel those that are not applicable and put the initials of the person assessing the risks.
17 Eye protection (the type of protection must be specified) _______________________________________________.
33 Hearing protection.
17 Respiratory protection equipment (the type of protection should be specified) __________________________________.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the location of the work? YES NO
If it is at height or cantilevered, also use list B25 or B30. If there are other risks due to the location, establish in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, examine data sheets of the Hazardous Substance and specify
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS?YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. Is there any other hazard not listed above?
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls.
Excuse me.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. Are instructions required at the workplace?
Instructions are generally required at the Work Site. If not, describe the reason.

Reason why they are not required:

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

LIST
SECURITY VERIFICATION No. B26
---------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Job supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL DANGERS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or the Site Instructions must be noted below and referred to in your
in the case of Specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with X in the boxes on the right.
Access points and escape routes must remain free of obstacles, and alternative routes should be identified and communicated to the staff.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
Rubber gloves and boots with toe protector, face shield, and appropriate clothing included in the work equipment.
You must notify the Authority of the area when you are going to start the activity.
The security alarm buttons must be functional.
Cables and hoses must be of a minimum length, free of temporary joints, not twisted, secured at intervals.
Regular and kept away from stairs, wet areas, and corridors. They should be protected where it is not possible to cover them.
7 The equipment, including any extensions such as poles and/or scaffolding, must be electrically grounded. The hoses
they are electrical conductors.
40 The hose connections must be secured at all points.
17 There should be a nearby eye wash station; if not, a portable station should be provided.
29 Oil spills and other fluids must be collected and/or cleaned up immediately.
17 Set up barriers to prevent unauthorized personnel from entering (Critical procedure for delineating risk areas)
(barricades) in PEP).
25 The delicate equipment must be protected.
31 An alternative warning method should be implemented where audible alarms cannot be heard.
25 The nozzles and guns must not be removed while the plant is operating.
40 The hoses should not be twisted during operation and must be depressurized when not in use.
25 The vents of the monitors should not face staff access, even if they are attached, and should not allow anyone to pass in front.
of the escapes.
25 The work must be carried out by a minimum of 2 people.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment and Controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

.................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B27
Oil paint application with sprayers only in hazardous areas or confined spaces.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED DANGERS: Add any additional dangers you consider necessary in the lines below (when required). If any danger
not applicable, cancel it by crossing out (X) the corresponding hazard number and also the numbers in
corresponding controls in sections 2, 3, and 11.

7 Static electricity spark 19 Flammable Substance

13 Chemical agents 40 Connection Failure / Pressurized Hose
Additional dangers: _____________________________________________ ___________________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), nullify those that are not applicable and
put the initials of the person assessing the risks.
19 Portable fire extinguisher for class 'B'/'C' fires available at the work site.
7 Verification tests for hydrocarbon gas will be carried out (specify frequency in the permit).
7 13 40 Put up barriers to prevent unauthorized personnel from entering (Critical procedure for delineating risk areas)
(barricades) in PEP).
7 Continuous monitoring must be carried out for the detection of gases derived from hydrocarbons.
13 The Checklist must take into account the necessary precautions for the hazardous substance, these precautions are
indicated in their respective safety data sheets.
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTION EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), cross out the non-applicable ones and put the initials of the person assessing the risks.
13 Appropriate personal protective equipment for handling hazardous substances.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the location of the work? YES NO
If it is in height or overhanging, also use list B25 or B30. If there are other risks due to the location, specify in section 1.
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
--------------------------------------------------------------------------------------------------------------------------------------------------- 5.
ARE THERE ADDITIONAL DANGERS DUE TO USED SUBSTANCES? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review safety data sheets of the Hazardous Substance and specify
controls in the Permit.
-------------------------------------------------------------------------------------------------------------------------------------------------
6. Are there additional hazards due to manual handling of materials? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify controls in the permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. Is there any other danger not listed above?
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls.
Excuse me.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE?
Generally, instructions are required at the work site. If not, describe the reason.

Reason why they are not required:...................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE RISKS OF THE ACTIVITY (APPLICANT).
The evaluation of all hazardous conditions has been completed, and it has been verified that all appropriate controls are in place.

Name
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B27
---------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Work Supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------

10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE

Any additional hazards identified in the Site Inspection or the Site Instructions must be noted below and referred to in your
In the case of Specific Controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with X in the boxes on the right.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
Access and escape routes must remain free of obstacles and alternative routes must be identified and communicated to staff.
The cables and hoses must be of a minimum length, free of temporary joints, not twisted, secured at regular intervals and
kept away from stairs, humid areas, and corridors. Where it is not possible to cover them, they must be protected.
7 The equipment, including any extensions, such as poles and/or scaffolding, must be electrically grounded, the hoses
they are electrical conductors.
40 The hose couplings must be secured at all points.
13 There must be available equipment to contain hydrocarbons or neutralize substances.
13 There should be a nearby eye wash station; if not, a portable station should be provided.
19 The drainage collectors in the immediate work area must be inspected and free from all combustible materials and protected.
with fireproof tarps (wet if necessary).
19 Flammable substances should not be used within one meter of hot surfaces.
40 Hoses should not be twisted during operation and must be depressurized when not in use.
13 The mixing of chemicals must be done in well-ventilated areas.
13 Food should not be consumed at the workplace.
19 Tank levels must be checked before and during filling.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS AT THE WORK SITE
The Instructions on the Job Site highlight the precautions in the Permit, the evaluation of Risks, and Controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been checked and are in place, and additional hazards are noted in section 10.

Work Supervisor: ................................................. Sheet/Company: .................................

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Revision December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B28
Change of railings, gratings, hatches or stairs.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD EVALUATION filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider important in the lines below (when required). If any hazard
not applicable, cancel it by crossing out (X) the corresponding number for the danger and also the numbers in
corresponding controls in sections 2, 3, and 11.

39 Unprotected opening
44 Failure of the lifting equipment
Additional hazards: _____________________________________________
.............................................................................. ..............................................................................
-------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permission (sections 3, 4, and 5), invalidate the non-applicable ones and
put the initials of who evaluates the risks.
39 44 Place barriers to prevent access to unauthorized personnel (Critical procedure for delimiting risk areas (barricades)
in PEP.
Additional controls: _________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), cross out the inapplicable ones and include the initials of the person assessing the risks.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the location of the work? YES NO
If it is elevated or suspended, also use list B25 or B30. If there are other risks due to the location, establish them in section 1 of
If it is in confined spaces use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------5.
Are there additional dangers due to substances used? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review the Safety Data Sheets of the Hazardous Substance and specify
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
YES NO
7. Is there any other danger not listed above?
Examine the hazards in sections 1, 4, 5, and 6, and any other relevant information. Identify additional hazards in section 1 and specify controls.
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Generally, instructions are required at the work site. If not, please describe the reason.

Reason why they are not required:...........................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

--------------------------------------------------------------------------------------------------------------------------------------------------------------------

SAFETY CHECKLIST NO. B28

---------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection Work or the Site Work Instructions must be noted below and referred to in your
Specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

11. INSTRUCTIONS
Please confirm by marking with X in the boxes on the right.
The personnel working near unprotected gates will wear a safety harness.
All areas above and below the workplace must be inspected in order to remove objects that could fall onto or ...
from the workplace.
Access and escape routes must remain free of obstacles and alternative routes should be identified and communicated to staff.
39 Where there is potential risk of falls (open accesses or free objects), the area must be marked with a barrier and signs installed.
preventive.
44 Lifting maneuvers must be visually inspected before being carried out.
44 The equipment and process or auxiliary lines should not be used to install rigging, scaffolding, or support loads.
44 The strobe lights or slings should be placed according to the specific load lifting manual.
---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS ON THE WORKSITE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Name
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS IN PLACE
All required controls have been verified and are in place, and additional hazards have been noted in section 10.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMISSIONNo
---------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. B30
Titulo Work at a height of 1.80 meters or higher, except on fixed walkways.
----------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider necessary in the lines below (when required). If any hazard
not applicable, cancel it by crossing out (X) the corresponding number for the danger and also the numbers in
corresponding controls in sections 2, 3 and 11.
31 Height
62 Severe / adverse weather condition
Additional hazards: _____________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), disregard those that are not applicable.
put the initials of the person evaluating the risks.

31 For work at heights, a competent worker must be present and in contact with the responsible personnel.
the operations of the control room.
31 Check the system or equipment before being used for work at height, in accordance with the manufacturer's instructions.
regarding possible wear, damage, deterioration, malfunction or other anomalies.
31 For work at height, a rescue plan for the worker must be in place.
31 Put up barriers to prevent access to unauthorized personnel (Critical procedure for delineating risk areas)
(barricades) in PEP).
62 In severe/adverse weather, activities must be suspended.
Additional controls:_________________________________________________________________________________________________________

3. PERSONAL PROTECTIVE EQUIPMENT:

Additional personal protective equipment specified in the Permit (box 3), strike through the non-applicable and put the initials of the person assessing the risks.
31 Safety harness.
31 Helmets with chin strap.
31 Personal protective systems to interrupt falls from height, when working on suspended scaffolding or
elevating platforms.
Are there additional dangers due to the location of the work?
If there is a risk of falling into the sea, also use list B25. IF
If there are other risks due to the location, establish in section NO
1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------
5. Are there additional dangers due to substances used? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review hazard data sheets and specify
controls on the Permit.
6. ARE THERE ADDITIONAL HAZARDS DUE TO MANUAL HANDLING OF MATERIALS?YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
7. IS THERE ANY OTHER DANGER NOT LISTED ABOVE?
YES
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls. NO
Permission.
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE?
Generally, instructions are required at the job site. If not, describe the reason. YES NO

Reason why they are not required:…

9. COMPLETE ASSESSMENT OF THE ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed, and it has been verified that all appropriate controls are in place.

.............................................................
Company:…........................

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. B30
---------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Work supervisor
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKSITE
Any additional hazards identified during the Job Site Inspection or Job Site Instructions must be noted below and referred to in your
In case of specific controls in section 5 of the permit by the applicant, who will place their initials next to each additional hazard.

…........................................................................... …...........................................................................
11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
You must notify the Authority of the area when you are going to start the activity.
The antennas will be isolated and the isolation certificate will be displayed on the work site.
31 The personnel must use a safety cable hooked to 2 separate points of anchorage in the main structure.
31 To descend, a safety rope is required, and both ropes must have 2 separate anchor points fastened to the structure.
principal.
Access and escape routes must remain free of obstacles and alternative routes must be identified and communicated to staff.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
31 Avoid the risk of falling objects by securing tools and equipment.
31 The equipment and process or auxiliary lines should not be used to install rigging, scaffolding, or support loads.
31 Supervise at all times that the personal fall protection system is used in accordance with the established instructions.
manufacturer.
31 Use a personal protective system for work at height to prevent falls from height.
31 Check the system or equipment before being used in the execution of work at height, according to the manufacturer's instructions.
regarding possible wear, damage, deterioration, malfunctioning or other anomalies.
31 Visually inspect, prior to use, the area where the ladder will be employed, in order to ensure that it does not
there are risk conditions when using a step ladder.
31 Immediately remove from service any defective ladders that may affect their safe use and are marked with the
Legend: 'Dangerous. Do not use.' or similar, to then proceed with its repair, disposal, or destruction.
31-62 Work at height must be suspended when the wind exceeds 45 km/h, if there is a risk of a blackout or thunderstorm.
31 The work must be carried out by a minimum of 2 people.
---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS AT THE WORK SITE
The Instructions on the Work Site emphasize the precautions in the Permit, the Risk Assessment, and Controls regarding these and other additional hazards.
identified in section 10

Instructions at the workplace given by:

Name
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards above 10 have been noted.

Supervisor del trabajo

Company
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMISSIONNo
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. B31
Assembly and disassembly of scaffolding in hydrocarbon production installations near pressure equipment
heated or electrical installations / equipment.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards that you consider necessary in the lines below (when required). If any hazard
not applicable, cancel it by crossing out (X) the corresponding danger number and also the numbers in
corresponding controls in sections 2, 3 and 11.

30 Heavy or difficult-to-grip object

31 Height
Additional dangers: ______________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permission (sections 3, 4, and 5), cancel those that are not applicable and
put the initials of the person assessing the risks.
31 For work at heights, a competent worker must be present and in contact with the personnel in charge of
the operations of the control room.
31 Check the system or equipment before being used in performing work at height, according to the manufacturer's instructions.
regarding possible wear, damage, deterioration, malfunction or other anomalies.
30 31 Place barriers to prevent access to unauthorized personnel (Critical procedure for delimiting risk areas
(barricades) in PEP).
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), strike out the inapplicable and put the initials of the person assessing the risks.
31 Lifeline.
31 Safety harness.
31 Helmets with chin straps.
31 Personal protection systems for interrupting falls from heights.
---------------------------------------------------------------------------------------------------------------------------------------------------
4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK? YES NO
If it is at height or suspended, also use list B25 or B30. If there are other risks due to the location, establish them in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, examine data sheets of the Hazardous Substance and specify.
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional hazards due to manual material handling? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
7. ARE THERE ANY OTHER RISKS NOT LISTED ABOVE? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls in the
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------
8. Are instructions required at the workplace? YES NO
Instructions are generally REQUIRED at the Work Site. If not, describe the reason.

Reason why they are not required:...........................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed, and it has been verified that all appropriate controls are in place.

Name
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. B31
---------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKSITE
Any additional hazards identified in the Site Inspection or the Site Instructions should be noted below and referred to in your
Specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

11. INSTRUCTIONS
Confirm by marking with X the boxes on the right.
All scaffolding must have a status card posted at all access points that must specify:
if the scaffolding is in usable condition.
the date and details of the last inspection.
the signature of the person who carried out the inspection.
When scaffolding is erected or dismantled, all equipment must be lowered or brought to the ground; for no reason should it be allowed to fall.
no material.
31 Personnel must use a safety cable attached to 2 separate points of anchor on the main structure.
31 Supervise at all times that the personal fall protection system is used according to the established instructions.
manufacturer.
31 Immediately remove from service any structures that have defects that may affect their safe use and are marked with the legend:
Dangerous. Do not use.
Access points and escape routes must remain free of obstacles and alternative routes must be identified and communicated to staff.
All areas above and below the workplace must be inspected in order to remove objects that could fall to or into
from the workplace.
31 Avoid the risk of falling objects by securing tools and equipment.
31 The equipment and process or auxiliary lines should not be used to install rigs, scaffolding, or support loads.
31 Work at height must be suspended when the wind exceeds 45 km/h, if there is a danger of a blackout or thunderstorm.
31 The work must be carried out by a minimum of 2 people.
---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS ON THE WORKSITE
The instructions on the job site highlight the precautions regarding the Permit, the assessment of risks and controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards above 10 are noted.

................................................................
Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMITNo:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. B34
title Use of photographic or video cameras in processing facilities.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
-------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED DANGERS: Add any additional dangers you consider necessary in the lines below (when required). If any danger
not applicable, cancel it by marking (X) the corresponding danger number and also the numbers in
corresponding controls in sections 2, 3, and 11.

5 Electric spark
Additional hazards: _____________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMIT CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), nullify the non-applicable ones and
put the initials of the person assessing the risks.
5 Portable fire extinguisher for class 'B'/'C' fire available on the job site.
5 Verification tests for hydrocarbon gas will be carried out (specify the frequency in the permit).
5 Continuous monitoring must be carried out for the detection of hydrocarbon-derived gases.
Additional controls:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), cross out non-applicable items and put the initials of the person evaluating the risks.
---------------------------------------------------------------------------------------------------------------------------------------------------
4. ARE THERE ADDITIONAL DANGERS DUE TO THE WORK LOCATION? YES NO
If it is at height or suspended, also use list B25 or B30. If there are other risks due to the location, state them in section 1 of
If it is in confined spaces use checklist A4. this Checklist and specify controls in the permit in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to substances used? IF NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass, or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, examine data sheets of the Hazardous Substance and specify
controls in the Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL HAZARDS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
7. IS THERE ANY OTHER DANGER NOT LISTED ABOVE? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls in the
Excuse me.
---------------------------------------------------------------------------------------------------------------------------------------------------
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Generally, instructions are required at the Workplace. If not, describe the reason.

Reason why they are not required:...........................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all the appropriate controls are in place.

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. B34
---------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL DANGERS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or the Site Instructions must be noted below and referred to in your
specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

11. INSTRUCTIONS
Confirm by marking with X the boxes on the right.
The requirement to use flash will be clearly established in the permit to the area authority to inhibit detection systems.
enclosing the isolation certificate.
Batteries should not be installed or removed in hazardous areas.
5 The equipment will be checked before entering the area.
All areas above and below the workplace must be inspected in order to eliminate objects that could fall onto or
from the workplace.

---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Name:
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Work supervisor
Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. B36
Pressure Testing of Plants, Pipes and Equipment.
---------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider relevant in the lines below (when necessary). If any hazard
not applicable, cancel it by crossing out (X) the corresponding number for the hazard and also the numbers in
corresponding controls in sections 2, 3 and 11.

25 High-pressure jet 40 Connection Failure / Pressurized Hose

28 Projectiles 42 Excess pressure in the container or system
Additional dangers: _____________________________________________ ____________________________________________________
.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permission (sections 3, 4, and 5), nullifying the non-applicable ones.
put the initials of the person who assesses the risks.
25 28 40 42 Put up barriers to prevent unauthorized personnel from passing (Critical procedure for delimiting risk areas
(barricades) in PEP).
42 The system must be isolated and the isolation certificate placed in a visible location.
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), put the initials of the person assessing the risks.
---------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional hazards due to the location of the work? YES NO
If it is elevated or suspended, also use list B25 or B30. If there are other risks due to the location, set them out in section 1 of
If it is in confined spaces use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass, or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, examine safety data sheets of the Hazardous Substance and specify
controls in the Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Specify in section 1 and detail Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------
7. IS THERE ANY OTHER DANGER NOT LISTED ABOVE? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls.
Excuse me.
---------------------------------------------------------------------------------------------------------------------------------------------------
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Generally, instructions are required at the work site. If not, describe the reason.

Reason why they are not required:

---------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE ASSESSMENT OF THE ACTIVITY RISKS (APPLICANT).
The evaluation of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

Name
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

---------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST NO. B36
---------------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Work Site Inspection or the On-Site Instructions must be noted below and referred to in your
if specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

11. INSTRUCTIONS
Confirm by marking with X the boxes on the right.
You must notify the Authority of the area when you are going to start the activity.
The pump used to raise the test pressure must have a relief valve below the maximum pressure design of the system.
The air will be vented from high points during the loading. When the system is emptied after testing, it must be taken into account
possibility of a vacuum and its effects.
Protective shields must be placed on the plugs of the inserts.
Approval from the control room is required before using water from the main system of the fire protection network to fill the system.
The system must be depressurized before repairing leaks.
42 The temporary connections must be adjusted to the maximum operating pressure.
40 The hose couplings must be secured at all points.
Access routes and escape routes must remain free of obstacles, and alternative routes must be identified and communicated to the staff.
28 Set up barriers to prevent unauthorized personnel from entering (Critical procedure for delimiting risk areas)
(barricades) in PEP).
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
42 The check valves of the non-return system must be removed.
40 The pressure increment ranges and pause periods must be as a testing procedure in the control room, advised
as necessary. Pressure tests should not be held longer than necessary.
40 Two recently calibrated indicators should be connected, one near the supply line and the other near the relief valve.
which are visible to the process control operator.
40 The discharge direction of the valve must be directed so that it does not endanger the plant and personnel if the valves
relevant.
25 The delicate equipment must be protected.
42 Those sensitive instruments and lines that do not withstand pressure tests must be replaced.
42 The weight and support restrictions for containers and pipes must not be exceeded with hydrostatic tests.
40 The cables and hoses must be of a minimum length, free of temporary joints, not twisted, secured at intervals.
Regularly and kept away from stairs, wet areas, and hallways. They should be protected where it is not possible to cover them.
40 Hoses should not be twisted during operation and must be depressurized when not in use.
40 No work or crane operation should be allowed in the area where tests are in progress.
40 Personnel not directly involved must be evacuated from the testing area before the tests begin. The equipment to
Use must be verified and used up to a reasonable period of time.
40 The system should not be loaded, tight, or hammered in any area under pressure.
25 The work must be carried out by a minimum of 2 people.
---------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS AT THE WORKSITE
The Instructions at the Workplace highlight the precautions in the Permit, the Risk Assessment, and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Name:................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS IN PLACE
All required controls have been verified and are in place, with additional hazards noted in section 10.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMISSION No:
-------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B39
Excavations deeper than 30 cm or where underground services may exist.
---------------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD EVALUATION filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add additional hazards you consider relevant in the lines below (when required). If any hazard is not
If applicable, cancel it by crossing out (X) the corresponding danger number and also the numbers in controls.
corresponding in sections 2, 3, and 11.

12 Hydrocarbon release 56 Trench opening without protection

34 Poor visibility / lighting Large object in motion
35 Possibility of getting trapped 64 Collapse of the excavation walls

Additional hazards: _______________________________________________ _____________________________________________________

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMIT CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), cancel the non-applicable ones and put the
initials of the person evaluating the risks.
12 Portable extinguisher for class 'B'/'C' fire available at the workplace.
56 64 Place barriers to prevent unauthorized personnel from entering (Critical procedure for the delimitation of risk areas (barricades) in
PEP)
12 Equipment available for confining hydrocarbons or neutralizing substances.
35 Personnel must exit a confined space immediately if the ventilation fails.
34 Provide temporary lighting.
Additional controls:_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
---------------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), strike through the non-applicable ones and put the initials of the person assessing the risks.
12 Respiratory protection equipment (the type of protection must be specified) ____________________________________________.
---------------------------------------------------------------------------------------------------------------------------------------------------------
4. ARE THERE ADDITIONAL DANGERS DUE TO THE LOCATION OF THE WORK? YES NO
If it is elevated or suspended, also use list B25 or B30. If there are other risks due to the location, state them in section 1 of
If it's in confined spaces use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO USED SUBSTANCES? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, examine hazardous substance data sheets and specify
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional hazards due to manual handling of materials? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
7. Is there any other unlisted danger? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls.
Excuse me.
---------------------------------------------------------------------------------------------------------------------------------------------------------
8. Are instructions required on the work site? YES NO
Generally, instructions are required on the work site. If not, describe the reason.

Reason why they are not required:...................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE RISK ASSESSMENT OF THE ACTIVITY (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

Name
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

--------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B39
---------------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or the Work Site Instructions must be noted below and referred to in your
In case of specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with X the boxes on the right.
You must notify the Authority of the area when you are going to start the activity.
12 Oil spills and other fluids must be collected and/or cleaned up immediately.
Access points and escape routes must remain free of obstacles, and alternative routes should be identified and communicated to the staff.
12-56-57 Set up barriers to prevent unauthorized personnel from entering (Critical procedure for the delimitation of risk areas)
(barricades) in PEP).
64 The supervisor must review the work area before starting activities and during their execution.
64 All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
35 Notify all personnel not involved in the activity about the start of the work and relocate them to a safe area.
Food should not be consumed in the workplace.

--------------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS ON THE WORK SITE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk assessment, and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Nombre
---------------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
---------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B40
Rigging and hoisting of lifeboats for navigation tests.
---------------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider necessary in the lines below (when required). If any hazard is not
If applicable, cancel it by crossing out (X) the corresponding number for the hazard and also the numbers in controls.
corresponding in sections 2, 3 and 11.

29 Slip risk 90 Loss of navigation aid

75 Failure of the lifting equipment 91 Escape and evacuation routes and equipment are reduced.

Additional dangers: _________________________________________________

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permission (sections 3, 4, and 5), invalidate those that are not applicable and put the
initials of the person evaluating the risks.
29 75 The lifting equipment must be certified and marked with safe operation.
29 The cable gauge must be appropriate for the use.
91 Place barriers to prevent access to unauthorized personnel (Critical procedure for delineating risk areas (barricades) in
PEP).
Additional controls:_________________________________________________________________________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), put the initials of the person assessing the risks.
---------------------------------------------------------------------------------------------------------------------------------------------------------
Are there additional dangers due to the work location? YES NO
If it is elevated or overhanging, also use list B25 or B30. If there are other risks due to the location, state them in section 1 of
If it is in confined spaces, use checklist A4. this Checklist and specify controls on the permit in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO USED SUBSTANCES? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review Safety Data Sheets of the Hazardous Substance and specify
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
7. Is there any other danger not listed above? YES NO
Examine the hazards in sections 1, 4, 5, and 6, and any other relevant information. Establish additional hazards in section 1 and specify controls.
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------------
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Generally, instructions are required at the Work Site. If not, describe the reason.

Reason why they are not required:...................................................................................................................................

---------------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPLETE EVALUATION OF THE ACTIVITY RISKS (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

--------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B40
---------------------------------------------------------------------------------------------------------------------------------------------------------
WORKSITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKSITE
Any additional hazards identified in the Job Site Inspection or the Job Site Instructions must be noted below and referred to in your
Specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with X the boxes on the right.
You must notify the Authority of the area when you are going to start the activity.
29-75 Access and escape routes must remain free of obstacles, and alternative routes must be identified and communicated to the staff.
29-75 The actual/estimated weight and center of gravity of heavy objects must be identified by the job requester to minimize
dangers during the maneuver.
The supervisor must review the work area before starting activities and during their execution.
All areas above and below the workplace must be inspected in order to remove objects that could fall towards or
from the workplace.
Food should not be consumed at the workplace.

--------------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS AT THE WORKSITE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

Name
---------------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards are noted in section 10.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
--------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B41
Work carried out on underground electrical records. As long as it is not considered a confined space.
---------------------------------------------------------------------------------------------------------------------------------------------------------
HAZARD ASSESSMENT filled out by the Permit Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------------
1. IDENTIFIED HAZARDS: Add any additional hazards you consider necessary in the lines below (when required). If any hazard is not
If applicable, cancel it by crossing out (X) the corresponding number for the hazard and also the numbers in controls.
corresponding in sections 2, 3, and 11.

8 Energized electrical conductors (fixed) 34 Poor visibility / lighting

29 Risk of slipping 35 Possibility of getting trapped

Additional hazards: ______________________________________________

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
2. PERMISSION CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), void the inapplicable ones and put the
initials of the person who assesses the risks.
8 29 35 The covers or lids must be placed in the workplace if it is to be left, even for short absences.
The work must be carried out by a minimum of 2 people.
29 34 35 Put barriers to prevent access to unauthorized personnel (Critical procedure for delimiting risk areas (barricades) in
PEP).
Additional controls:_________________________________________________________________________________________________________
translatedText
---------------------------------------------------------------------------------------------------------------------------------------------------------
3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (box 3), write the initials of the person evaluating the risks.
---------------------------------------------------------------------------------------------------------------------------------------------------------
4. ARE THERE ADDITIONAL DANGERS DUE TO THE WORK LOCATION? YES NO
If it is at height or cantilevered, also use list B25 or B30. If there are other risks due to the location, specify in section 1 of
If it is in confined spaces use checklist A4. this Checklist and specify controls in the permission in section 2.
---------------------------------------------------------------------------------------------------------------------------------------------------------
5. ARE THERE ADDITIONAL DANGERS DUE TO THE SUBSTANCES USED? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review hazardous substance data sheets, and specify
controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Establish in section 1 and specify Controls in the Permit.
---------------------------------------------------------------------------------------------------------------------------------------------------------
7. Are there any other dangers not listed above? YES NO
Examine the hazards in sections 1, 4, 5, and 6 and any other relevant information. Establish additional hazards in section 1 and specify controls in the
Permission.
---------------------------------------------------------------------------------------------------------------------------------------------------------
8. ARE INSTRUCTIONS REQUIRED ON THE WORKSITE? YES NO
Generally, instructions are required on the work site. If not, describe the reason.

Reason why they are not required:

---------------------------------------------------------------------------------------------------------------------------------------------------------
9. COMPREHENSIVE RISK ASSESSMENT OF THE ACTIVITY (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

....................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

--------------------------------------------------------------------------------------------------------------------------------------------------------
SAFETY CHECKLIST No. B41
---------------------------------------------------------------------------------------------------------------------------------------------------------
WORK SITE VERIFICATION filled out by the Work supervisor
---------------------------------------------------------------------------------------------------------------------------------------------------------
10. ADDITIONAL HAZARDS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Site Inspection or the Site Instructions must be noted below and referred to in your
in case of Specific controls in section 5 of the Permit by the applicant, who will put their initials next to each additional hazard.

.............................................................................. ..............................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
11. INSTRUCTIONS
Confirm by marking with an X the boxes on the right.
You must notify the Authority of the area when you are going to start the activity.
29 Set up barriers to prevent unauthorized personnel from entering (Critical procedure for delineating risk areas
(barricades) in PEP).
35 The supervisor must review the work area before starting activities and during their execution.
All areas above and below the workplace must be inspected in order to remove objects that could fall to or
from the workplace.
Food should not be consumed at the workplace.

--------------------------------------------------------------------------------------------------------------------------------------------------------
12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Work Site highlight the precautions in the Permit, the Risk Assessment, and Controls over these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

.................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------
13. CONTROLS ON SITE
All required controls have been verified and are in place, and additional hazards have been noted in section 10.

Supervisor del trabajo

Company:...........................
---------------------------------------------------------------------------------------------------------------------------------------------------------

Review December 2012

 PERMIT No:
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SAFETY CHECKLIST No. B42
Title: Maneuvers and transportation of equipment or material whose volume or weight imply a special risk due to difficulty or
complexity in its handling with force equipment, where the simultaneous use of 2 or more units is required (such as
telescopic cranes, articulated hydraulic cranes "HIAB"; booms; fifth wheel; "direct tow"; winches, etc.
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HAZARD EVALUATION filled out by the Permit Applicant
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1. IDENTIFIED HAZARDS: Add additional hazards you consider in the lines below (when required). If any hazard
not applicable, cancel it by crossing out (X) the number corresponding to the hazard and also the numbers in
corresponding controls in sections 2, 3, and 11.

23 Inertia of objects in general 62 Severe/adverse weather condition

30 Heavy or difficult-to-grip object 75 Failure of the lifting equipment
34 Poor visibility / lighting 93 Communication failure
40 Connection Failure / Pressurized Hose
Additional hazards: _____________________________________________ ____________________________________________________
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2. PERMIT CONTROLS: The following controls must be specified in the Permit (sections 3, 4, and 5), and disregard those that are not applicable.
put the initials of the person assessing the risks.
23 The load should be secured in order to reduce oscillatory movements.
23 30 75 Barriers and signs must be placed.
30 75 The tie-downs must be tested prior to the lifting.
34 Activity should be suspended when visibility is limited.
40 The hydraulic connections must be checked and activity should be suspended in case of any leaks.
93 Alternate communication measures must be available and tested.
62 Work should be suspended when the wind exceeds 45 km/h, or when the support of the equipment is reduced.
75 The cables, slings, strops, and other lifting devices must be inspected.
75 The equipment must be tested and properly maintained according to the manufacturer's standards.
75 Verify and test, according to the operating routine, the correct use, arrangement, and functioning of the devices to ensure the
stability of the equipment, such as stabilizing bars or legs.
Additional controls:_________________________________________________________________________________________________________

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3. PERSONAL PROTECTIVE EQUIPMENT:
Additional personal protective equipment specified in the Permit (table 3), put the initials of the person who evaluates the risks.
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Are there additional dangers due to the location of the work? YES NO
(Near hydrocarbon pressurized systems, you must use checklist A9 and class A permit)
If it is elevated or cantilevered, also use list B25 or B30. Other risks due to location, such as ground instability.
Underground services that may be affected by the weight of the Set in section 1 and specify controls on the permit.
team. Establish in section 1 and specify controls in Cables or installations that are located within the reach of the arm or
the permit. of the load.
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Are there additional dangers due to substances used? YES NO
If working with radioactive sources, LSA scale (Low Specific Activity), Halon, Asbestos, Fiberglass or Mineral, or others, use checklist A5.
Other hazardous substances. Establish in section 1 of this Checklist, review safety data sheets of the Hazardous Substance and specify
controls in the Permit.
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6. ARE THERE ADDITIONAL DANGERS DUE TO MANUAL HANDLING OF MATERIALS? YES NO
For example, are there heavy or long objects to be handled? Specify in section 1 and outline Controls in the Permit.
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7. Is there any other danger not listed above? IF NO
Examine the hazards in sections 1, 4, 5, and 6, as well as any other relevant information. Establish additional hazards in section 1 and specify Controls in the
Permission.
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8. ARE INSTRUCTIONS REQUIRED ON THE WORK SITE? YES NO
Generally, instructions are required at the workplace. If not, describe the reason.

Reason why they are not required:......................................................................................................................................

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9. COMPLETE RISK ASSESSMENT OF THE ACTIVITY (APPLICANT).
The assessment of all hazardous conditions has been completed and it has been verified that all appropriate controls are in place.

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Review December 2012

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SAFETY CHECKLIST NO. B42
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WORKSITE VERIFICATION filled out by the Work Supervisor
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10. ADDITIONAL DANGERS IDENTIFIED IN THE WORKPLACE
Any additional hazards identified in the Work Site Inspection or the Work Site Instructions must be noted below and referred to in your
specific controls in section 5 of the Permit by the applicant, who will place their initials next to each additional hazard.

.............................................................................. ..............................................................................
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11. INSTRUCTIONS
Confirm by marking with X the boxes on the right.
All areas above and below the workplace must be inspected in order to remove objects that could fall to or from the
work site and rule out the existence of underground services or lines (drainage, water, instrumentation, etc.).
Access and escape routes must remain free of obstacles, and alternative routes must be identified and communicated to the staff.
The cables and hoses must have a minimum length, be free of temporary connections, not twisted, secured at regular intervals and
kept away from personnel transit areas.
Lifting operations will not be performed on unprotected high-pressure pipes or equipment.
When there are electrical cables that hinder or limit maneuvering or transport, they will only be handled or manipulated by
qualified personnel, always with the right tools and in constant communication with the operator.
No personnel should be transported on the equipment platform or on the load.
23 The load will be secured in order to reduce oscillatory movements.
93 Alternate forms of communication must be available and tested.
93 If the signals for communication between the men and the operator of the maneuver are lost (due to noise or obstruction) designate
additional staff to ensure communication.
62 Work should be suspended when the wind exceeds 45 km/h, or when visibility or equipment support is reduced.
75 The lifting maneuvers must be planned and visually inspected before being carried out.
75 The slings or straps must be placed according to the specific load lifting manual.
75 The cables, slings, strops, and other lifting devices should be inspected.
75 The proper functioning of the devices that ensure the stability of the lifting equipment, such as bars or will be tested and verified.
stabilizing legs.

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12. INSTRUCTIONS IN THE WORKPLACE
The Instructions on the Work Site highlight the precautions in the Permit, the assessment of Risks, and Controls regarding these and other additional hazards.
identified in section 10.

Instructions at the workplace given by:

............................................................
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13. CONTROLS ON SITE
All required controls have been verified and are in place, with additional hazards noted in section 10.

Work Supervisor

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Revision December 2012