Anda di halaman 1dari 1

HOT

Evidence No. 04 MAIN PERMIT No. .


WORK PERMIT
Petroserv Management
DATE SHIFT DAY NIGHT
Endorsement Work Order No. :

Y
IT
From

D
LI PROCEDURE Attached : YES NO

E
VA

M
TI
To Drawing / P&ID'S Attached : YES NO

Work Location. Equipment Name / No.


INITIATOR

Description of Work to be performed

COMPLEMENTARY PERMIT REQUIRED : YES NO


COMPLEMENTARY PERMIT TYPE :
PERFORMER (IVQ Candidate) PERFORMING AUTHORITY ( Petroserv Principal )

Name : I authorizedto
I authorize an IVQ Candidate a Snr. Technician
receive the toPermit
receive and
the permit and observe
observe requirements :
requirements
Roll No. : Name :
Batch : Function : Signature :..

Hazardous area Classification: Circle 0 11 2 2JOB SAFETY ANALYSIS (JSA) / RISK ASSESSMENT REQUIRED : Yes NO

Gas test is required Gas Tester's Name : Signature :


Gas test is not required Note : Gas test must be carried out immediately prior to commencement work
Time FLAMMABLES (HC) H2S O2 TESTER'S SIGNATURE REMARKS

Complementary Permit / Mech.


REQUIREMENTS FOR SAFE WORKING CONDITIONS Sr.No. IVQ Candidate is authorized to start Work
Isolation Certificate
STATUS PLANT SYST. EQUIP. Yes No.
A U T H O R I T Y (Petrosere Operations Director)

1 In service
2 Shut down REMARKS
3 Depressurized
4 Drained
5 Water flushed 20 Continuous gas Monitoring
6 Inerted with 21 CO2 / Halon / Inergen isoloated
7 Pressurized with 22 Fuel gas blinded
8 Blanketed with 23 Elec. Circuits isolated & tagged
9 Full of (specify) 24 F&G / ESD system(s) override required
10 Empty 25 Equipment is hot
11 Mech. Isolation Certificate attached 26 Tool box meeting required
12 Isolated mechanically & tagged by: 27 Fire watch required
a) Blanking / spading 28 Portable Gas monitor required
b) Disconnected 29 Fire net work under pressure
c) Valving 30 Fire hose lengthened
13 Open Vessel / Piping 31 Portable fire alarm positioned
14 Gas Free 32 Foam protection
15 Steamed 33 Mobile fire water monitor Area Authority
16 Ventilated 34 Portable fire extinguisher at site
Continuity bonding /Earthing required Name :.
17 a) CO2
18 Safety system(s) by passed / inhibited b) Dry Chemical Powder Signatrure Time :
19 Scaffolding 35 Flame retardant partion
SAFETY REQUIREMENTS FOR IMPLEMENTATION BY PERFORMER (ADVISED BY AREA AUTHORITY) PERFORMING AUTHORITY
1 Appropriate Protective Clothing # Low / Non Sparking Tools
Name :.
AREA

2 Goggles / Face-shield # Dust Mask


3 Ear Muffs # Barriers & warning signs installed Signature :
4 Hand protection # Sewers, drains, gutters, etc. within
5 Life jacket 15m (50ft) of work site sealed Date : Time :
6 Safety belt / Harness & lifeline # Materials in vicinity including other floors
7 Combustible material cleared & levels protected from flames & sparks PERFORMER
8 Escape route cleared / provided # Adequate lighting / search lights
Name :.
9 Fresh air mask / SCBA to be worn # H2S trained personnel only
10 Escape Set # Coolant Signature :
11 Portable Gas Monitor # Others (Specify)
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 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.
Starting at hours Date : Area Authority Name : Signature :

I hereby declare that the work detailed in this Permit has been completed / stopped in a safe condition and that de-isolation & re-
instatement may take place and that the worksite has been left in a clear, clean and safe condition and that every person assigned has
WORK COMPLETION / 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
CLEARANCE exception of :...........................................
NAME DATE TIME SIGNATURE
Performing Authority
Acknowledged by Area Authority
ORIGINAL - Performer , 1st copy - Area Authority , 2nd copy - HSE

Minat Terkait