**Part 1: To Be Completed by Subcontractor/Vendor**

> **Submission of this completed form is a prerequisite for Performing
> Work in MSD Laboratories.**
>
> [Instructions]{.underline}: Complete this form for all on-site
> service, warranty and repair work and return it to the LBNL equipment
> manager. Identify all hazards that could be present in your scope of
> work. If a box is checked "Yes", then additional documentation may be
> required. If you have any questions in filling out this document,
> please contact Rick Kelly at (510)486-4088. Submission of this form
> meets requirements specific to the Materials Sciences Division at
> LBNL. All other applicable Institutional requirements still apply.

Date Prepared Estimated start time and length of job

Subcontractor Phone Cell Phone

Prepared by: Job Title Phone

[Subcontractor Point of contact: Phone: e-Mail:]{.underline}

+----------+-----------------------------------------------------------+
| Scope of |                                                           |
| Work;    |                                                           |
|          |                                                           |
| *Doing   |                                                           |
| what,    |                                                           |
| where,*  |                                                           |
|          |                                                           |
| *with    |                                                           |
| what     |                                                           |
| ma       |                                                           |
| terials* |                                                           |
+----------+-----------------------------------------------------------+

Job Location (Bldg. No.) /Site):

**Yes No**

1\. ** ** **Facility Modification** -- Does the scope of your job
include any modifications to our facility? If so, describe below.

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2\.   **Utilities Shut-Off**

Does the work involve shutting off any electrical circuits, water, gas,
or steam valves, or other utilities?

If so, specify which utilities are to be shut off.

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Describe the hazards involved and how you will protect the worker.

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Lock and tag procedure-See LBL EHS manual, Chapter 18 for minimum
requirements (http://www.lbl.gov/ehs/pub3000/CH18.html).

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3\.   **Electrical Work**

** ** Will work be performed on any electrical component or equipment
(i.e., work involving installation, demolition, modification or testing
and analysis of electrical equipment or conductors)? If so, describe
below

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Describe the hazards involved and how you will protect the worker.

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  Will your work be performed near any open or exposed electrical
energized equipment or energized circuits (greater than 50 volts)? If
so, describe below.

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Describe the hazards involved and how you will protect the worker

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4\.   **Personal Protective Equipment-**Does the scope of the work
involve hazards that require the use of any of the protective equipment
listed below?

+---+-----------------+------------------+----------------------------+
|  | Safety Glasses  | Describe eye     | Describe how you will      |
|   |                 | hazard.          | protect the worker.        |
+---+-----------------+------------------+----------------------------+
|  | Ear plugs or    | Describe noise   | Describe how you will      |
|   | ear muffs       | hazard.          | protect the worker         |
+---+-----------------+------------------+----------------------------+
|  | Steel toes      | Describe foot    | Describe how you will      |
|   | shoes           | hazard.          | protect the worker.        |
+---+-----------------+------------------+----------------------------+
|  | Gloves          | Describe hand    | Describe how you will      |
|   |                 | hazard           | protect the worker.        |
+---+-----------------+------------------+----------------------------+
|  | > Respirators,  | Describe         | Describe how you will      |
|   |                 | airborne hazard. | protect the worker.        |
|   |                 |                  |                            |
|   |                 |                  | [Attach:]{.underline}      |
|   |                 |                  |                            |
|   |                 |                  | > Respiratory Protection   |
|   |                 |                  | > Plan:                    |
+---+-----------------+------------------+----------------------------+
|  | > Electrical    | Describe the     | Describe how you will      |
|   | > personal      | electrical       | protect the worker.        |
|   | > protective    | hazard.          |                            |
|   | > equipment     |                  |                            |
+---+-----------------+------------------+----------------------------+
|  | > Other         | Describe the     | Describe how you will      |
|   | > personal      | hazard.          | protect the worker.        |
|   | > protective    |                  |                            |
|   | > equipment     |                  |                            |
+---+-----------------+------------------+----------------------------+

5\.   **Fall Protection**-- Will you be working at heights above 6
feet and within 15 feet of an unprotected edge? If so, describe the work
which will require fall protection.

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Describe the hazards involved and how you will protect the worker.

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6\.   Fire Protection/Prevention --Will your work include the use of
open flames such as torches, welders, grinders, tar pots or any other
tool or process/procedure that could cause sparks or open flames? Will
work be performed near combustible storage containers? Describe below.

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Describe the hazards involved and how you will protect the worker.

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7\.   **Refrigeration Repair or Maintenance**. Will your work include
work on chillers? If so, describe below.

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Describe the hazards involved and how you will protect the worker.

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8\.   **Power & Hand Tool** Will your work require the use of
dangerous power and hand tools, e.g.; circular saws, axes, chisels,
etc.? If so, list the tools and describe their use below.

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Describe the hazards involved and how you will protect the worker.

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9\.   **Hazard Communication/Toxic** **Substances**-- Will the scope
of your work require the use of hazardous substances? If so, check all
that apply below and include requested information.

+---+--------------------------+----------------------------------------+
|  | Chemicals or chemical    | -   List materials or products         |
|   | related products         |                                        |
|   |                          | -   Describe the process involving the |
|   |                          |     chemicals.                         |
|   |                          |                                        |
|   |                          | -   Describe hazards involved and how  |
|   |                          |     you will protect the worker.       |
+---+--------------------------+----------------------------------------+
|  | Gases                    | -   List gases, including quantities,  |
|   |                          |                                        |
|   |                          | -   Describe the process involving the |
|   |                          |     gases,                             |
|   |                          |                                        |
|   |                          | -   Describe how you will protect the  |
|   |                          |     worker                             |
+---+--------------------------+----------------------------------------+
|  | Biological materials     | -   List all biologicals               |
|   |                          |                                        |
|   |                          | -   Describe the working involving the |
|   |                          |     biologicals                        |
|   |                          |                                        |
|   |                          | -   Describe how you will protect the  |
|   |                          |     worker.                            |
+---+--------------------------+----------------------------------------+
|  | Flammable materials,     | -   List materials,                    |
|   | including flammable      |                                        |
|   | adhesives and glues      | -   Describe the work involving the    |
|   |                          |     flammables.                        |
|   |                          |                                        |
|   |                          | -   Describe how you will protect the  |
|   |                          |     worker.                            |
|   |                          |                                        |
|   |                          | -   Attach your Hazard Communication   |
|   |                          |     Program.                           |
+---+--------------------------+----------------------------------------+
|  | Radioactive materials or | -   List all materials/devices         |
|   | radiation generating     |                                        |
|   | devices \> Class1        | -   Describe the work involving        |
|   |                          |     radioactive materials or radiation |
|   |                          |     generating devices.                |
|   |                          |                                        |
|   |                          | -   Describe how you will protect the  |
|   |                          |     worker.                            |
|   |                          |                                        |
|   |                          | -   Attach your radiation protection   |
|   |                          |     program. G                         |
+---+--------------------------+----------------------------------------+

10\.   Excavation of Ground Surfaces and Penetration of Existing
Concrete Structures Will the scope of your work require you to perform
any mounting to walls or penetration (including chipping) into the
ground, walls, floors, sub floors, and/or any excavation, trenching,
including the use of stakes or poles? Describe including the depth of
the penetration.

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Describe the hazards involved and how you will protect the worker.

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11\.   Confined Space Entry Will the scope of your work require you to
be working in a confined space (including manholes) where combustible,
toxic, or other hazardous materials are present.

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Describe the hazards involved and how you will protect the worker.

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Attach your Confined Space Program.

12\.   Lead Paint Removal Will the work involve sanding, grinding,
scraping, brazing, welding, or otherwise disturbing painted surfaces in
such a way that particles may become airborne? If so, describe the scope
of work you will be performing that disturbs the lead.

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Describe how you plan to control the spread of airborne lead and protect
the worker.

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13\.   **Painting Walls** Does the scope of your work include sanding
walls and/or ceilings or washing of exterior walls (There is a potential
for disturbing lead or asbestos)? If so, describe.

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Describe the hazards involved and how you will protect the worker

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14\.   **Asbestos** Will the subcontractor work with asbestos? Is so,
describe the scope of your work that will involve removing the asbestos,
how much asbestos your will be removing.

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Describe the hazards involved and how you will protect the worker.

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Attach your asbestos program.

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15\.   **Lasers** Will you be working on Class 3B or Class 4 lasers or
microwave sources greater than 5 mW/cm2, including warranty work. If so,
describe your scope of work.

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.

Describe the hazards involved and how you will protect the worker

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Attach your laser safety program.

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16\.   Radiation Safety Will radiography be performed or radioactive
materials or ionizing radiation sources be used? If so, describe the
hazards below and how you will protect the worker.

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17\.   **Other** -- Identify any other hazard associated with this job
and the controls you are planning on using to protect the worker.

.

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**Part 2: MSD Permit for Vendor Services (Installation, Maintenance &
Repair Work)**

**Equipment Manufacturer: Permit \#**

**Installation/Service Vendor:**

**MSD Laboratory Contact: Phone \#**

**Building Room Equipment**

**Vendor Technicians (Print)**

Lead:

Lead technician phone \#

Other phone \#

**Required Institutional Permits**

Hot work Penetration Conf. Space EEW Radiation

[Comments:]{.underline}

Approved by Date

**THIS PERMIT IS VALID FOR A PERIOD OF ONE YEAR FROM THE APPROVAL DATE
FOR THE SCOPE OF WORK DESCRIBED HEREIN BY THE LISTED SERVICE PERSONNEL.
ANY CHANGE IN PERSONNEL OR SCOPE OF WORK REQUIRES A NEW REVIEW AND
EITHER AN UPDATE OF THIS PERMIT OR A NEW PERMIT.**

**[PERMIT MUST BE DISPLAYED AT THE JOB SITE DURING WORK]{.underline}**