Permit Request • CampusOptics

It is requested that the noted building system have Lockout/Tagout by the owner to allow for our time-in services for the project as enumerated below. The Environmental Health and Safety Department requires a (1) week advance notice given (as a minimum) for research facilities and all lockout/tagout will occur during regular working hours. I hereby certify the required work has been coordinated and scheduled to be completed within the requested time period and that the Contractor understands lockout/tagout the procedure that is being used.

Requester

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Contractor Lockout/Tagout Request

Project Name/Number:* Required

Has the Contractor been instructed not to remove lockout/tagout devices or start de-energized equipment unless they are the authorized personnel who placed the lockout/tagout? * Required

Did the Contractor verify that the equipment was de-energized? * Required

Did the Contractor follow the lockout/tagout procedure? * Required

Description of work to be performed:* Required

Emergency Phone Contact (After Hours) Name:

Emergency Phone Contact (After Hours) Phone #

Environmental Health and Safety Remarks:

Contractor Remarks:

Coordination Meeting required prior to shut down?

If yes, coordination Meeting Date:

Check with UT Tyler Power Plant/Utilities prior to starting and upon ending work: 903-566-7030

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files