ExxonMobil Pipeline Company

ExxonMobil Company

Contractor Safety Waiver Request

To be Completed by the Waiver RequestorContracting Company Name: SILICON SWP BVWaiver is requested for (Check all that apply) FORMCHECKBOX BRRF FORMCHECKBOX BRCP FORMCHECKBOX BRFP FORMCHECKBOX BRPO FORMCHECKBOX BRPP

FORMCHECKBOX New Contractor FORMCHECKBOX Existing Contractor

Name of Project/Job for Safety WaiverAnticipated Start DateEstimated Completion Date

Pcla-3 2015 Ta 12/15/146/15/15

Provide a brief description of the type and scope of work to be performed: Technical & installation services for Rapid Arc Welding for refractory anchor installation. What is the Safety Risk Level for Contracting Company for this waiver? FORMCHECKBOX 1 FORMCHECKBOX 2 (Waiver form not needed for level 3 contractors)Level 1 are those who provide services essential to daily operations in all areas of the site and have a direct impact on process safety or the health/safety of the individual/others. (see attachment for safety level definitions)Level 2 are those who provide services essential to daily operations in all areas of the site and has no impact on the process safety and minimal impact on the health/safety of the individual/others. (see attachment for safety level definitions)How are existing onsite services being covered contractually? FORMCHECKBOX Existing CSA FORMCHECKBOX Spot Contract FORMCHECKBOX SAP PO FORMCHECKBOX Subcontracting by other site primary contract company

Justification: Provide(Reason(s) supporting the safety waiver request and not using an ACL supplier (use additional pages if needed): FORMCHECKBOX Low Cost Supplier FORMCHECKBOX Better Safety statistics FORMCHECKBOX Sole Source Provider of Services

If the job involves any type of electrical work to be performed by the contractor, the person(s) performing the work must be electrical T1-BP certified. Contact Zone 27 (225-977-1358) for certification info. Note: Short Service Workers (SSWs) should not be used during live electrical work. Contact Zone 27 (225-977-1358) for further guidance.Attachment: Start of the Job Checklist (SOJC) Contractor/ExxonMobil Pre-Job Meeting Summary table 2 must be completed at least annually table 1 can be used if table 2 has been completed within the last 12 months Dan Songy 11/20/14

Requesters TitleSignature

Date

To be Completed by the Contracting Company:

How long has your company provided the services described in section A? 22 Years

Is your company a member of the North American Substance Abuse Program ( NASAP ) program? Yes, via ASAP Drug Solutions. We will switch to new membership in JanuaryIs your company a member of the North American Background Screening Consortium ( NABSC ) program?

No, currently awaiting enrollment from DISA to become member.Do your employees have a TWIC card? YesIs your company a member of the Houston Area Xnet? NoDoes your company have a Louisiana Contractors License?No If no, please explain? Has your company ever worked in an ExxonMobil facility?

If yes, which facility? Is your company on any other ExxonMobil site approved Contractors list?

If yes, which facility and provide a brief description of work completed? REQUIRED ATTACHMENTS:

Attachment: Contractor Risk Mitigation Plan - Actions are to address specific risks identified If deemed necessary by the ExxonMobil Safety Department (for level 1 suppliers)

Attachment: Xnet participation. If not in Xnet provide specific procedures for the scope of services provided

CONTRACTOR SAFETY REPORTING REQUIREMENTS -- INJURY/ILLNESS TREATMENT PROTOCOL

The Baton Rouge BRRF/BRCP Complex has established an on-site Occupational Health Clinic (225-977-0005) at a central location on 12th Street in the Refinery. Unless otherwise directed by Turnaround or Project requirements, all site contractors with non-emergency work-related injuries or work-related illnesses are to be evaluated by and receive first aid through the on-site clinic during the hours the clinic is open (Normal hours of operation are Monday thru Friday 6:00 AM 6:00 PM, excluding holidays).

Site Contractors are required to have an After-hours Offsite Occupational Health Care Provider:

FORMCHECKBOX

CORE Occupational

FORMCHECKBOX

Gulf Coast Occupational Medicine

FORMCHECKBOX

Prime Occupational Medicine

FORMCHECKBOX

Other**Name of Facility or Doctor:

Address:

Phone:

Div. Mgr. Review

*Contract supervision understands that non-emergency injury evaluation and treatment shall be administered by an occupational clinic and not a local hospital emergency room.

**Requires Division Manager review.

To be Completed by the Contracting Company: (Continued)

Safety Benchmarks:

YEARTRIRLTIREMRFatality (Number)

YTD0000

Year 1 data (most recent full year data)0000

Year 2 data0000

Year 3 data 0000

3 year average0000

Contractor Company Representative Signature: _________________________________________________To be Completed by the ExxonMobil Site Safety Department:

Based on the above safety benchmarks and work description, is a risk mitigation plan needed?

Yes FORMCHECKBOX

No FORMCHECKBOX

Based on the information provided by the Contractor, does this Contract Company meet site requirements to be added to the approved contractors list (ACL)?Yes FORMCHECKBOX

No FORMCHECKBOX

Safety Department Comments:

ExxonMobil Site Safety DepartmentSignature

Date

Approval Signatures to be obtained by Waiver Requester

Requester's SLSSignature

Date

Manager's TitleSignature

Date

FORMCHECKBOX Denied -

Reason:

HOW TO COMPLETE THE SAFETY WAIVER REQUEST FORM

AThe waiver requestor is to provide a brief description of the work that will be performed by the contractor for which the exception is being requested. This will assist the ExxonMobil Safety Facilitator in reviewing the contractor's mitigation plan (if required by Safety) for level 1 suppliers and ExxonMobils SOJC to determine if it is adequate based on the level of risk associated with the work to be performed. Also, the waiver requester will determine the safety risk level with assistance from safety, contracts administration, and the OIMS 8.1 coordinator and determine how the onsite services are being covered contractually.

BProvide reason for needing to use this particular contractor even though they may present a higher risk potential than another contractor currently on the ExxonMobil ACL. Note any other contractors that can perform this type of work and why they are not being used.

CThe contractor for which the requestor is seeking a safety waiver is to complete the Contractor Section of this form. Also, the Contractor will complete a Contractor Risk Mitigation Plan (if required by Safety). This plan will be the primary basis for which a contractor is either granted or denied a safety waiver. This is the plan the contractor will enact based on the deficiencies identified in the screening process to ensure a safety incident does not occur on ExxonMobil projects or property. A separate plan is to be completed for each risk factor identified. Some examples of risk mitigation actions might include the following:

Supervision requirements (field presence, job monitoring, safety observations, etc.)

More frequent implementation of specific safety tools, practices and processes

Reference Site Safety Standard, Work Procedure or IH Guideline to be specifically emphasized

Additional requirements for site, work area, equipment and tool inspections

Selection of specific contractor personnel based on type of work and hazards

Requirements for full time safety support on site

Continuous assessment of safety systems and their hazard management effectiveness

Frequency and content of safety meetings and hazard analysis/management processes

Schedule for reviews (status check) of this plan with ExxonMobils job Coordinator throughout this job

The ExxonMobil representative requesting the services of this contractor along with his/her supervisor have agreed the need to use this contractor outweighs the safety risk and potential exposure. The completed plan is to be attached to the safety waiver form after it is reviewed by the requestor for further processing.

DThis section is provided by the contracting company. In most cases an average of the TRIR will be taken for the most recent three year period and used to compare with the screening requirement. If three years are not available then the most recent information available will be used.

This section of the process requires the contractor to prepare documentation that discusses the actual injuries/illnesses recorded on their OSHA log for the years being reviewed, the cause of the injuries/illnesses for each of the years in question, any plans they have put into place to resolve the reoccurrence of these injuries/illnesses and specific plans they have to mitigate similar risks on this particular ExxonMobil project.

An approved safety waiver is only for a particular project or specified period of time. If the contractor is to be used on another project or by a new requestor, a new safety waiver form must be approved. The safety waiver may be granted for the length of the project, which may be more than one year, but if the exception is only for a period of time the maximum is one year. At the end of the year new safety statistics numbers will be reviewed to see if they meet ExxonMobil requirements for inclusion on the ACL. If not, a new safety waiver form and mitigation plan must be submitted.

EThis section is to be reviewed and approved by the ExxonMobil Safety Facilitator. The safety waiver requestor may be asked to provide additional information about the project name and or time period for which the contractor will be used.

FSignature sections of the form. Signatures needed from requestor, requestor's SLS, Safety Facilitator, and requesters Department Head. Waiver requester completes the electronic security waiver noting that the contractor safety waiver request form and SOJC have been completed.

Note: Upon job completion, send completed SOJC and completed safety waiver form & risk mitigation plan to the Contractor Safety Office at 165 EMPR

CONTRACTOR SAFETY LEVELS

The Safety Level is determined by the nature, location and duration of the work to be performed. Careful consideration must be given to the potential for exposure to worksite hazards and hazards of the work being performed, on the contractor and other individuals when assigning the Safety Level. The Level is based on the highest risk work the contractors' employees will perform while on site. If a contractor performs work under multiple contracts, the same Level is assigned for each onsite contract.

Safety Risk Level 1 - High relative safety risk Contractors (Level of Compliance I) are those who provide services essential to daily operations in all areas of the site and have a direct impact on process safety or the health/safety of the individual/others.

Examples: new construction, dismantling, electrical, water blasting, chemical cleaning, insulation, process computer, instrumentation, pipefitting, welding, millwrights, structural steel, painters, radiographers, asbestos & lead abatement, leak repair, catalyst exchange, remediation, waste management, environmental services, drafting and engineering on process units, any service that connects/operates to process equipmentSafety Risk Level 2 - Medium relative safety risk Contractors (Level of Compliance II) provides services essential to daily operations in all areas of the site and has no impact on process safety and minimal impact on the health/safety of the individual/others.

Examples: janitorial work, vehicle mechanics, building and grounds, telephone repair, cafeteria, If level 2 contractors need to visit a Process area, they must be accompanied at all times by ExxonMobil personnel or a safety level 1 contractor.. A

B

C

D

E

F