Evidence No.

04
DATE
SHIFT From DAY

HOT WORK PERMIT

NIGHT Petroserv Management Endorsement

MAIN PERMIT No. .

Work Order No. : PROCEDURE Attached : Drawing / P&ID'S Attached : YES YES NO NO

LI

IT

VA

TI M

E
To

INITIATOR

Work Location.

Equipment Name / No.

Description of Work to be performed COMPLEMENTARY PERMIT REQUIRED : PERFORMER (IVQ Candidate)

YES NO

COMPLEMENTARY PERMIT TYPE :

PERFORMING AUTHORITY ( Petroserv Principal )

I authorizedto a Snr. Technician receive and the permit and observe requirements : I authorize an IVQ Candidate receive the to Permit observe requirements Name :

Name Roll No. :

Batch : Function : Hazardous area Classification: Circle

Gas test is required Gas test is not required Time
FLAMMABLES (HC)

Signature :..
(JSA) / RISK ASSESSMENT REQUIRED : Yes NO

JOB SAFETY ANALYSIS 1 1 2 2

Gas Tester's Name : Note :

H2S O2 TESTER'S SIGNATURE REMARKS

Signature :

Gas test must be carried out immediately prior to commencement work

REQUIREMENTS FOR SAFE WORKING CONDITIONS

Complementary Permit / Mech. Isolation Certificate

EQUIP.

Sr.No.

IVQ Candidate is authorized to start Work Yes No.

A U T H O R I T Y (Petrosere Operations Director)

STATUS

PLANT

SYST.

1 2 3 4 5 6 7 8 9 10 11 12

13 14 15 16 17 18 19
1 2 3 4 5 6 7 8 9 10 11

In service Shut down Depressurized Drained Water flushed Inerted with Pressurized with Blanketed with Full of (specify) Empty Mech. Isolation Certificate attached Isolated mechanically & tagged by: a) Blanking / spading b) Disconnected c) Valving Open Vessel / Piping Gas Free Steamed Ventilated Continuity bonding /Earthing required Safety system(s) by passed / inhibited Scaffolding
Appropriate Protective Clothing Goggles / Face-shield Ear Muffs Hand protection Life jacket
Safety belt / Harness & lifeline

REMARKS 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Continuous gas Monitoring CO2 / Halon / Inergen isoloated Fuel gas blinded Elec. Circuits isolated & tagged
F&G / ESD system(s) override required

Equipment is hot Tool box meeting required Fire watch required Portable Gas monitor required Fire net work under pressure Fire hose lengthened Portable fire alarm positioned Foam protection Mobile fire water monitor Portable fire extinguisher at site a) CO2 b) Dry Chemical Powder 35 Flame retardant partion
# # # # Low / Non Sparking Tools Dust Mask Barriers & warning signs installed Sewers, drains, gutters, etc. within 15m (50ft) of work site sealed
& levels protected from flames & sparks

Area Authority Name :. Signatrure

PERFORMING AUTHORITY

Time :

SAFETY REQUIREMENTS FOR IMPLEMENTATION BY PERFORMER (ADVISED BY AREA AUTHORITY)

AREA

Name :. Signature : Date :

PERFORMER

Time :

# Materials in vicinity including other floors # # # # Adequate lighting / search lights H2S trained personnel only Coolant Others (Specify) Name :.

Combustible material cleared Escape route cleared / provided Fresh air mask / SCBA to be worn Escape Set Portable Gas Monitor

Signature : Date : Time :

We the Performing Authority and Performer declare that we are aware of the work scope and we ensure that all personnel under our responsibilities will not
perform any other activity. We have checked the work site conditions and can confirm that details of all the precautions,protections and safety equipment specified on this Work Permit are in place and that site preparation is satisfactory for this Permit to proceed , and we shall conduct an HSE Tool Box Talk prior to commencing the work, covering the hazards and safety precautions required. We hereby ensure that the tools to be used are checked and found appropriate and in good condition.
AUTHORIZATION FOR WORK BY AREA AUTHORITY Starting at

I hereby declare that all the above HSE requirements have been identified / completed and I authorize the work to be carried out . This work is valid only for the period specidied by the initiator, and as per the conditions specified above.
Date : Area Authority Name : Signature :

hours

WORK COMPLETION / CLEARANCE

Performing Authority Acknowledged by Area Authority

I hereby declare that the work detailed in this Permit has been completed / stopped in a safe condition and that de-isolation & reinstatement may take place and that the worksite has been left in a clear, clean and safe condition and that every person assigned has been withdrawn and F&G/ESD system(s) returned to service. The equipment is / is not in a condition to be retuned to service with the exception of :...........................................

NAME

DATE

TIME

SIGNATURE

ORIGINAL - Performer , 1st copy - Area Authority , 2nd copy - HSE