Line Break Permit

Form 000.653.F0129 Line Break Permit

Project Name Project No./Contract No. -

Project Location Requestor Name Date

Description of Work

Special Instructions

Personal Protective Equipment Check Check Other Protective Measures (PPE) Required Yes No Yes No

Air Pack – Approved Barricade - ______Radius (above/ below) Boots – Rubber Boots Blanks to be Installed Coveralls -Tyvek Block Valve Shut Film Badge Blower Gloves – Long Gloves Fire Extinguisher Gloves – Leather Gloves Grating, Floor Opening Covered Gloves – Rubber Gloves Lockout Plan Required Goggles Piping Support Installed/Needed

Hood – Acid Hood Planning (Line Break Planning Items Page 2 completed and distributed to all personnel0 Respirator – Full-Face Respirator involved) Respirator – Half-Face Respirator Pump Locked Out Shield – Face Shield Spark Proof Tiles Shield – Special Shielding Standby Person Suit – Acid Suit System Less Than 212 °F (100 °C).

Suit – Hot Suit System Vented Suit - Rain Valve Locked Out Other: Water Hose Other: Other: Other: Other: Other Other: Other: Other:

Planning Items for Line Breaks

1. Depressurizing, Cleaning, and Venting Check

Nearest Safety Shower Location (if greater than 50 feet 2. [15.2 meters], water hose must be provided)

3. Nearest Eyewash Location

4. Cold Pak Location

5. Scott Air Pak Location

6. Fire Extinguisher Location

7. Fire Alarm Location

8. Stretcher Location

9. Planned Escape Route

Relaxing PPE Requirements Date Time

PPE reduced to items shown below:

Approval Name Signature Date Client Representative

P2S Supervisor

Person Making Break

Line Break Permit Issuer

Note: This form is referenced in Practice 000.653.3320.