**SAFETY APPROVAL FORM**

*For Experiments/Tests/Work to be Conducted at 9300/9500 Facilities*

**I. Facility** [Z Facility]{.underline} **Facility Organization**
[1636]{.underline}

> A. Scheduled Test/Work Dates: [     ]{.underline}
>
> B. Actual Test/Work Dates (and Shot Numbers) [     ]{.underline}

**II. User Identification** [     ]{.underline}

**III. Experiment/Test/Work** **Identification & Brief Description**
[     ]{.underline}

**IV. ES&H Documentation**

A. Hazard Identification List See attached

B. Safety Authorization Basis Remarks

X PHS [PHS 9716335313 Z Facility]{.underline}

HA [     ]{.underline}

X ECL (NEPA) [TA-IV Environmental Assessment DOE/EA-1153]{.underline}

X Other [Z Facility Safety Assessment Documentation]{.underline}

C. Work Control Remarks

X SOP [Refer to facility SOP list located in library]{.underline}

X OP [Refer to facility OP list located in library]{.underline}

X Checklist [Refer to facility OP list located in library]{.underline}

X RWP [RWP for Z Operation and Unload]{.underline}

X Hot Work Permit [Hot Work Permit used periodically for hot
work]{.underline}

X Confined Space Permit [Confined space permits used for all confined
spaces]{.underline}

X Training [Refer to Facility Training Database]{.underline}

X PPE [PPE used as prescribed in facility SOPs and OPs]{.underline}

Other [     ]{.underline}

D. Other Remarks

Mfr's Instructions [     ]{.underline}

Other [     ]{.underline}

Other [     ]{.underline}

Other [     ]{.underline}

**V. Administrative** **Approvals**

> A. Experiment Certification:
>
> With my signature, I hereby certify that I will not proceed with this
> experiment until all the appropriate approvals have been obtained.
> Furthermore, I hereby certify that all personnel associated with, or
> supporting, this particular experiment have been properly trained to
> safely execute the experiment and to safely handle all expected
> hazards.
>
> **[     ]{.underline}**

*Signature of Principal Investigator Recommended Safety Class*

> B. Line Approvals:
>
> **Class I** - The risks from all hazards are within previous reviews
> and approvals.
>
> Approved Date

*Machine Operator*

Not Class I, forwarded to Machine Safety Committee

> Approved Date

*Machine Operator*

> **Class II** - The risk from a hazard exceeds previous reviews and
> approvals.
>
> Approved Date

*Department Manager*

Not Class II, forwarded to Pulsed Power Safety Committee

> Approved Date

*Department Manager*

> **Class III** - The risk from a previously unreviewed/unapproved
> hazard may result in a loss-of-time injury or exceed a property loss
> of \$50K.
>
> This activity is not subject to the requirements of DOE Order 5480.25.
>
> This activity does not involve an Unreviewed Safety Issue.
>
> Approved Date

*PPSC Chairman*

> Approved Date

*Center Director*

**HAZARD IDENTIFICATION LIST**

Use this list as a guide when completing the Hazard Analysis (HA).
Remember that mitigations include 1) engineered controls, 2) personal
protective equipment, 3) training, and 4) administrative controls.
Include appropriate personnel from the 9000 ES&H Support Team to help
you review this list.

**[HAZARDS MITIGATIONS]{.underline}**

[Electrical Hazards]{.underline}

Yes No Capacitors [     ]{.underline}

Yes No Transformers [     ]{.underline}

Yes No Batteries [     ]{.underline}

Yes No Electric Arcs [     ]{.underline}

Yes No Exposed conductors [     ]{.underline}

Yes No Wiring [     ]{.underline}

Yes No Cable runs [     ]{.underline}

Yes No Electrostatic [     ]{.underline}

Yes No 120V or less [     ]{.underline}

Yes No 121V or more [     ]{.underline}

Yes No Other [     ]{.underline}

[Gravity Hazards]{.underline}

Yes No Suspended objects [     ]{.underline}

Yes No Cranes, hoists, slings, rigging, forklifts [     ]{.underline}

Yes No Scaffolds and ladders [     ]{.underline}

Yes No Excavations, canals [     ]{.underline}

Yes No Elevated doors, floors [     ]{.underline}

Yes No Elevators, stairs, railings [     ]{.underline}

Yes No Lifting [     ]{.underline}

Yes No Surfaces, obstructions (falling, tripping, slipping, bumping)
[     ]{.underline}

Yes No Other [     ]{.underline}

[Hazardous Materials, Substances, and Waste]{.underline}

Yes No Explosives or other energetic materials [     ]{.underline}

Yes No Flammable/combustible solids, liquids, gases [     ]{.underline}

Yes No Corrosives (acids, caustics) [     ]{.underline}

Yes No Etiologic agents (virus, bacteria, etc.) [     ]{.underline}

Yes No Toxic material, poisons [     ]{.underline}

Yes No Oxidizers [     ]{.underline}

Yes No Metals (Be, Cd, Hg, Pb, solders, etc.) [     ]{.underline}

Yes No Solvents (halogenated, nonhalogenated) [     ]{.underline}

Yes No Radioactive material/fissile material [     ]{.underline}

Yes No Asphyxiants (inert gases or vapors) [     ]{.underline}

Yes No Reactive or spontaneously combustible materials
[     ]{.underline}

Yes No Irritating materials [     ]{.underline}

Yes No Metal working fluids [     ]{.underline}

Yes No Adhesives [     ]{.underline}

Yes No Material compatibility during storage or transportation
[     ]{.underline}

Yes No Hazardous or mixed waste generation [     ]{.underline}

Yes No Environmental releases (air, soil, surface water, groundwater)
[     ]{.underline}

Yes No Other [     ]{.underline}

[Mechanical Hazards]{.underline}

Yes No Power tools, common shop equipment [     ]{.underline}

Yes No Pulleys, belts, gears, etc [     ]{.underline}

Yes No Motors, pumps, fans [     ]{.underline}

Yes No Compactors, crushers [     ]{.underline}

Yes No Transportation (motor vehicles, electric/gas carts)
[     ]{.underline}

Yes No Vibrations, oscillations [     ]{.underline}

Yes No Chips, fragments, shrapnel, other flying objects
[     ]{.underline}

Yes No Shears, presses, sharp edges, pinch points [     ]{.underline}

Yes No Other (kinetic/potential energy) [     ]{.underline}

[Pressure Hazards]{.underline}

Yes No Boilers and other pressure vessels [     ]{.underline}

Yes No Stressed mechanical systems, springs [     ]{.underline}

Yes No Vacuum [     ]{.underline}

Yes No Noise [     ]{.underline}

Yes No Hydraulic systems, jacks [     ]{.underline}

Yes No Compressed gases [     ]{.underline}

Yes No Other [     ]{.underline}

[Radiant Energy Hazards]{.underline}

Yes No Intense light [     ]{.underline}

Yes No Lasers (Cat I & II) [     ]{.underline}

Yes No Lasers (Cat III & IV) [     ]{.underline}

Yes No Ultraviolet, infrared light [     ]{.underline}

Yes No Magnetic fields, RF fields, microwaves [     ]{.underline}

Yes No Ionizing radiation producing machines [     ]{.underline}

Yes No Other [     ]{.underline}

[Thermal Hazards]{.underline}

Yes No Heaters, furnaces [     ]{.underline}

Yes No Steam, steam lines [     ]{.underline}

Yes No Plasma, flames, welders [     ]{.underline}

Yes No Friction [     ]{.underline}

Yes No Refrigerating units [     ]{.underline}

Yes No Cryogenic materials [     ]{.underline}

Yes No Other [     ]{.underline}

[Additional Hazards]{.underline}

Yes No Confined spaces (oxygen deficiency) [     ]{.underline}

Yes No Poor housekeeping (ingress/egress, lighting, etc)
[     ]{.underline}

Yes No Effects of other facilities, operations, traffic routes, etc
[     ]{.underline}

Yes No Natural elements (ice, snow, wind, rain, lightning, dust)
[     ]{.underline}

Yes No Snakes, insects, spiders, other animal life [     ]{.underline}

Yes No Other [     ]{.underline}

*Signature Date Signature Date*

*Signature Date Signature Date*