PLANT SERIAL NO.

PERMIT TO WORK
NO WORK THAT IS SO URGENT THAT WE CANNOT TAKE TIME TO DO IT HOT WORK
HOT WORK PRECAUTIONS (To Be Filled by Respective RA/AA)
: : :.. : Name Signature Date/Time Requisition Date: Time: Expected Completion Date: Time: : . :.. :. :.

Makhostia

SECTION 1: REQUISITION (To Be Filled By Applicant)

APPLICANTS NAME STAFF NO./ IC NO. LOCATION/ FACILITY EQUIPMENT NO. DEPT./CO. CONTACT NO. AREA UNIT MWO NO.

TYPE OF HOT WORK Hot Tapping Open Flame Phyrophoric Flammable Release Spark Producing Vehicle Entry Other:

CONDITIONS TO BE IMPLEMENTED BY RA/ RAR Remove Flammable Material Locate Spark Producing Equipment Away From Sewer/ Trench Fire Extinguisher Spark Arrestor Fire Hose on Standby N2 or Steam Purge Cover sewer/ drain/ sump Hot Tapping Procedure Attached Fire Blanket Other: Fire Retardent Screen Fire Watch Name:

ENDORSED BY RA
:. :. :.

WORK DESCRIPTION:

SECTION 2: HAZARD/ HAZARDOUS ACTIVITIES (To Be Filled by RA/AA)

Excavation Interlock Bypass Work at Height Hot Tapping Pressure Test
Head, Eyes & Face

LOCK OUT TAG OUT (LOTO)

Key Safe No: Key Safe Key No:

Special Precautions: ..

Welding Radiography Grinding Hot Cutting Confined space Entry High Pressure Junction Box Opening Moving Eqmt Parts Loading/ Unloading Power Tool
Respiratory Hearing Hand

Electricity Flammable Material Generator/ Compressor Falling Vehicle Ergonomic: Crane Chemical
Foot

CONFINED SPACE ENTRY CERTIFICATE (To Be Filled by Respective AA)

TYPE OF ALLOWED Respirable Atmosphere Harmful Atmosphere Irrespirable Atmosphere CONDITIONS TO BE IMPLEMENTED BY RA/RAR Extra Low Voltage (50V) Locate mobile equipment away from manhole Barricade and Signs Confined Space Entry Checklist Attached Personnal Oxygen Monitoring Meter Fire Watch Name: Personnel H2S Meter Continuous Gas Monitoring Rescue & Evacuation Plant Attached Continuous Ventilation Breathing Apparatus to be Used
SCBA Airline Half Mask Full Face

Noise Other: .
Body

SECTION 3: PERSONNEL PROTECTIVE EQUIPMENT (To Be Filled By RA/AA)

Fall Protection Gas Monitoring

Helmet Half Mask Respirator Ear Plug Goggles/ Safety Glass Full Face Respirator Ear Muff Face Shield SCBA/ Airline Set

Cotton Glove Leather Glove Rubber/ Chemical

Glove

Safety Shoes/ Boot Coverall Full Body Toxic Gas Monitor Safety Rain Boot Chemical Suit Hardness Personnel District Unit Live Vest Fall Arrest Eqmt LEL Gas Meter Apron O2 Meter

SECTION 4: SUPPORTING CERTIFICATES/ DOCUMENT (To Be Filled By RA/AA)

Safety Sys. Bypass/ Override Certificate No.: ... Electrical Iso. Certificate No.: .. Physical Isolation Certificate No.: ... Electrical Work/ Limitation of Elect. Access
Certificate No.: ...

Excavation Certificate No.: ... Radiation Certificate No.: ... Lifting Certificate No.: ... Road Obstruction Certificate No.: ... Vehicle Entry Certificate No.: ...

Pre Job Minutes of Meeting Authority Clearance (JKR, TNB, JPS, STM, PFN) DOSH Permit To Install Scaffolding Certificate Sob Safety Analysis (JSA)

Drawing No.: Previous PTW No: Method Statement Safety Briefing Certificate

RA REPRESENTATIVE
Name Designation Signature
: .. : : Date: ..

AA REPRESENTATIVE
I have personally checked the area and equipment to be worked on and satisfy the work requested can be carried out safely

Name: .. Designation: ..

Signature: . Date:

Acknowledge by RA/RAR: Name: . Signature: Date: . Time: ..

I had personally checked that all control measures to prevent release of hazard have been put in place and complied with those condition under this certificate

SECTION 5: WORKSITE PREPARATION/ PRECAUTIONS (To Be Filled By RA/AA)

PRECAUTION TAKEN BY AA CONDITION TO BE IMPLEMENTED BY RA/RAR

Approving Authority Scaffolding Erected Ad Safe To Be Used Equipment/ Line Spade as per Attached List Contact Area/ Panel Operator on Work Start To Be Accompanied By Area Operator/ AGT Others:

Signature

Department

Designation

Date

Positive Identification (Tagged) Equipment/ Line Drain/ Depressurize/ Purge Valves Isolation Flushed With Water Valve Chained Locked open/ Close RA REPRESENTATIVE
Name Designation Signature

N2 Purged/ Steam Out Secure Tools/ Materials Against Falling Locked Out Tag Out (LOTO) To be Counter Signed By Others:

Running Water On Locked Out Tag Out (LOTO) Barricade & Warning Sign Contact Area/ Panel Operator
on Completion

GAS TESTER CERTIFICATE (To Be Filled By Authorized Gas Tester, AGT)

Frequency of Gas Test: Gas Tester (GT) Brand:__________________

Continuous
Time

Every Two Hours O2 (Vol %) LEL/ CH4 (Vol %)

Every Four Hours

CO (ppm) CO2 (ppm)

Other (please specify): H2S (ppm) Benzene (ppm) GT Calibration Due Date

Signature

JOINT SITE VISIT BEFORE WORK START (MANDATORY)

AA REPRESENTATIVE
I have personally checked the area and equipment to be worked on and satisfy the work requested can be carried out safely

: : : Date: ..

Name: .. Designation: .

Signature: .. Date:

TLV (ppm)

19.5 23.5

5000 (10%)

50

5000

10

10

SECTION 6: PERMIT APPROVAL/ REVALIDATION

AGREED BY RECEIVING AUTHORITY (RA) Name: Date: Signature: Time: RA/RAR SURRENDERING PTW
NAME/ SIGN DATE/ TIME

APPROVING AUTHORITY (AA) Name: Date: Signature: Time:

AGREEMENT BY RA REPRESENTATIVE (RAR) Name: Date: Signature: Time: AA ISSUING PTW

NAME/ SIGN DATE/ TIME

Gas Test For:

Hot Work

Confined Space: This Entry Permit is Valid Until Time: Date: AGT No. Signature Date time

I personally conducted gas test as per above result and satisfy the work requested can be carried out safely

Authorized Gas Tester (AGT) Name

TRANSFER RECORD/ REVALIDATION

AA RECEIVING SUSPENDING PTW
NAME/ SIGN DATE/ TIME

RA/RAR REISSUED PTW

NAME/ SIGN DATE/ TIME

SECTION 7: HAND BACK (To be Filled by RA/RAR)

Work Completed Incomplete Hand Back (Equipment Status, Reason for Hand Back, etc) Housekeeping

HAND BACK BY RAR
Name: Signature: Date: Time: Name: Signature:

COMPLETED BY RA
Date: Time: Name: Signature:

ACCEPTED BY AA
Date: Time:

Permit Distribution:

Original: Displayed at Work Site

Copy No.1: Receiving Authority

Copy No. 2: Approving Authority/DCS

STOP WORK AND EVACUATE AREA ON HEARING OF EMERGENCY ALARM