CO R E PE RM I T SEEDS

CORE Permit #:
Initials Date # permits

EMERGENCY PHONE A S S E M B LY
NUMBER: LO C AT I O N :

1. PEOPLE
Permit issuer PRINT SIGN Phone number
Plant/facility Number of people working under this permit
Co-signature PRINT SIGN Name(s) of people working under this permit P R I N T N A M E S o r AT TA C H L I S T
Issuer transferred to PRINT SIGN Receiver transferred to PRINT SIGN

Permit receiver PRINT SIGN Company Date

On-site inspection required by issuer YES NO Start time AM/PM End time AM/PM

Work limited to the following JOB SCOPE / DESCRIPTION / TASKS & AREA / EQUIPMENT & BOUNDARIES Additional Attachments:

All people working under this permit have the necessary site training and/or orientations YES N/A

Emergency procedures have been reviewed and are understood (alarms, locations of assembly points and evacuation routes) YES N/A 2. ENVIRONMENT
Emergency equipment has been located and reviewed
(Examples include, but are not limited to: nearest safety shower, eye wash, fire extinguisher and telephone and/or intercom) YES N/A Potential environmental impact & procedures for N/A
addressing impact: spills and/or leaks
The scope and boundaries of any other work in the area that could impact this permitted work has been reviewed and is understood YES N/A

Other workers in the area have been notified that this permitted work could impact their work, including the locations of any barricades YES N/A

All equipment to be worked on has been properly prepared and identified and is ready to work on YES N/A Waste disposal & housekeeping requirements: N/A
All energy sources, including radiation, are isolated, tagged and confirmed YES N/A

For demolition and renovation work, has the work area been inspected for asbestos YES N/A

A procedure is in place and reviewed for tasks as required by department Procedure Use Policy (PUP) YES N/A Special atmospheric monitoring requirements: N/A
Line of fire hazards have been discussed and mitigation techniques will be in place YES N/A

Fall hazards are present and an additional assessment will need to be completed (ladders, scaffold) YES N/A

Job site inspection required see standard for exceptions. Extended use/additional inspection needed YES N/A
Ergonomic concerns & safeguards: N/A
Job site inspector Mon___ Tues___ Wed___ Thur___ Fri___ Sat___ Sun___
Start time AM/PM End time AM/PM Start time AM/PM End time AM/PM

3. ENERGY 4. EQUIPMENT 5. CHEMICAL

For the scope of work, check the appropriate permit List the hazards of the area, the work and the List below any contained process chemical(s) or
below. Fill out the checklist or permit and attach it to this N/A N/A job specific chemical(s). See Safety Data Sheet(s) N/A
equipment for the specific task.
CORE Permit using the same number as the CORE permit. for review of safety & health hazards.
Line/Equipment Opening Permit Excavation Noise Pinch Points Radiation
Hot Work Permit Hydroblasting Thermal burn Sharp edges Inert atmosphere
Confined Space Entry Permit Pressure washing Flash fire Heat stress Asbestos
Critical Elevated Work Permit Energized electrical work Pressure extreme Flying debris Vibrations HAZARDS
Crane Operation Permit Rigging Permit Falls Dust type: _____________
Isolations of Energy (IOE) IOE master #: _________ ___________ Flammable Inhalation Toxic Skin absorption
Electrical/high voltage
______________ Skin irritant Corrosive Reactive _____________

6. PROTECTION
Head / Face
Hard hat/bump cap
Welding hood
Chemical hood type:
_______________
Hearing protection
Double hearing protection
Face shield
Chemical goggles
Safety glasses with
side shields
Safety glasses - foam seal
_____________________
Comments: Reason for upgrading or downgrading PPE
Protection required for hazards - list personal protective equipment, precautions and safeguards
required to protect against hazards. place an asterisk (*) beside any personal protective equipment
with specific requirements/upgrade/downgrade, then define in section below.
7. WORK ENVIRONMENT
Hands Arms / Body Respiratory Feet / Legs Elevated Work
Access Prevention Protection
Chemical resistant Chemical suit type: Supplied air Safety shoes
gloves type: _____________________ Ladder Guardrail Harness w/ lanyard
_____________________ Full face purifying Closed Toed Shoes
Tyvek type: Mobile scaffold Restraint line Vertical lifeline
_____________________ Powered air purifying Rubber boots - ankle
Mechanical Welding Aerial lift devices Retractable lifeline Safety net
1/2 face purifying Rubber boot - calf high
Leather Thermal Nomex (FRPC) Flash suit Scaffold Designated area: Horizontal lifeline
Dust mask Metatarsal protection
Welding jacket _______________ ______________ Defined anchor point:
Electrical Gauntlet Cartridge type:
Apron type: Knee pads _______________
Cut resistant - level: _____________________ _____________________
_____________________ _____________________ Thigh protection Barricades Caution/Danger tape Physical _________________
Lab coat Long sleeve
_____________________ High visability/reflective _____________________ _____________________ Additional requirements Signage
_____________________ _____________________ _____________________ _____________________ ___________
Electrical GFCI Written operating procedure
Communication type: Safety attendant(s) required: ___________
__________________ Name: ________________
___________
Limited time exposure: Fire extinguisher
(breaks, etc) ___________
__________________ ______________________

8. TRAINING 9. CORE PERMIT RECEIVER 10. RESPONSIBILITIES

Workers have specialty training as required: N/A The Core Permit Receiver will ensure that all workers: Responsibilities communicated to permit receiver:

Equipment PPE use Understand the hazards of the area, equipment and work and the safeguards in place. Conditions for work stoppage
Understand potential environmental impact and procedures for addressing this. Reporting changes that affect job safety
Powered industrial truck Competent person
Understand and follow Personal Protective Equipment requirements. Crew accountability & addressing workers’ concerns
Aerial work platform Hazwoper
Have the necessary skills and knowledge to do the permitted work safety.
PCB, PMN, 5e Certified Reporting a change in the permit receiver
Know emergency procedures, alarm and assembly points.
_____________________
Asbestos Qualified person Know the location of and how to use emergency equipment.
Lead _________________ Know the scope of other work that could impact this work. Permit receiver:
Understand the scope of this permitted work. Initials Phone #

11. CHANGE 12. CLOSEOUT

Scope changed Hazards changed Control measures changed Closeout job site inspection completed? YES N/A Receiver closeout: Issuer closeout:
Status of job and equipment reviewed? YES N/A
STOP WORK - notify permit issuer for review! SIGNATURE SIGNATURE
Additional paperwork reconciled? YES N/A
If suspended, reauthorize permit to continue work!
Special instruction, precautions, limitations, remarks: Date Time
Issuer SIGNATURE
AM/PM
Receiver SIGNATURE

Date Time AM/PM CORTEVA. CORE PERMIT. LAST UPDATED MAY 2019.