Building_____________ Room#________________

Type of work to be performed:_______________________________________

Date(s):________________ Time: From_________To_________

Shop Performing the Hot Work:____________________________________________________

On-Site Liaison:_____________________________________ Phone #:________________

EH&S Staff Issuing Permit:______________________________________ Phone #:________________

Date Permit Issued:________________

Remember: *All Hot Work Permits must be called into Power Plant Base prior to work commencement. (Phone #442-3444)

*All completed Permits must be sent to EH&S in Chemistry B73.