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PERMIT TO WORK-COLD WORK No.

:SSL/CW PERMIT NO-

1 Specification of Work Mark All Boxes Y (Yes), N (No) or NA (Not Applicable) Valid for a shift-After This permit Renewal Required

Date of Application Applicant /Performing Authority Name Department

Location of Work Equipment Name Equipment no.

Description of work

Name of Persons Working As per Annexure


Note : ( Separate sheet to be attached in case of insufficient space above or change of persons during work)
Name of the working Agency

Tools & Equipments

2 Hazards Identified
Confined Space Tripping Hazard Excavation Collapse High Voltage Heavy Lifts Hazardous Substances

High pressure jet Pressurised Pipework Electrocution Fall from Height Steam Pressurised Hose Failure

Slipping Hazards Ackward Access Flammable Material Hydrocarbon Area Noise Chemical Hazard

Inadequate Lighting Dropped Objects Radioactive Source Static Electricity Vibration Drowning

Simultaneous Opn Lone worker Other Hazards


Note: Attach Annexure for more Hazards if space is less

3 Controls in Place
A Initial Gas Testing Oxygen Content Check Continuous Gas Test Fire /Safety Watcher Portable Fire Extinguishers

Signs & Barricading Scaffolding Safe Access/Egress De-pressurised Interlocks Required

MSDS Precautions Additional Lighting Hose Whip Check Lifting plan/Equipment Intrisically Safe Equipment

Draining Purging Vented Secure Loose Objects Manual Handling Equipment

Simultaneous opn identified and Risk accessment done Equipment Earthing & Bonding Flammables Removed Radioactivity Controls in Place

Note: Attach Annexure for more Hazards if space is less

B Additional PPEs Standards - Helmets, Safety Shoes and Safety Goggles are mandatory

Leather Gloves Electrical Gloves Cotton Gloves PVC Gloves Heat Resistant Gloves

Maintenance Gloves Aluminium Suit Chemical Splash sheild Leg Guard Face Shield

Dust Mask/SCBA Arc Flash Suit Safety Harness Steam resistant gloves & Suit Tool Box Meeting

C Job safety Analysis HIRADeC are mandatory for all work associated with safety Systems HIRADeC & SWP/WI/SOP/SMP No:

D Additional Controls
Note : Sl No 1 to 3 Needs to be filled one day in advance from the Actual Work Execution Day and Annexures to be added if space is less anywhere

4 Isolation Required
Isolation Certificate Cert No. Confined Space Certificate Cert No. Excavation Certificate Cert No.

Height Work Certificate Cert No. High Voltage Switching certificate Cert No.

5 Authorised By SBU/Section Head Affected Area Authority Project In charge


I/we agree this work can proceedd provided all the above identified controls are in place and the precautions adheredd to by the work party

Name Signature Designation Date Time

Note : The Above Authorization is required for Identified Critical Jobs & for unplanned Emergency Jobs to be started on the same day

6 Issue
I the Shift Incharge / Area Authority ,declare that all hazards have been identified and all control measures are
in place and it is now safe for the work specified on this permit to be performed and is valid. I the Field Engineer/Operator confirms that all hazards identified and all control measures specified are in
From : To : place and it is now safe to carry out the work specified on this permit.
hrs hrs From : hrs To : hrs

Name Signature Designation Date Time Name Signature Designation Date Time

I the Performing Authority, have read and understood the above conditions and precautions. I accept responsibility for carrying out the work as specified.I will ensure the persons under my control read,understand and comply
with these conditions and precautions.I will notify the Operation Shift Incharge / Area Authority on completion or interruption of this work.

Name . Signature Designation Date Time

7 Permit Renewal

Date:
From:

To:

Shift Incharge /Area


Authority (Issuer) - Name

Shift Incharge /Area


Authority (Issuer) - Sign

Performing Authority

8 Permit Sign of
Performing Authority: I declare that all persons have been withdrawn and that all tools,plant and equipment
used have been removed and the site left in a safe clean and tidy condition.

The Work is complete The Work is Incomplete

Name (print) Signature Designation Date Time

Shift In Charge ( Issuer ) I declare the work task is :- Complete Incomplete Isolations/Overrides can be removed:

Long term Isolations/Overrides required Remark for Long term Isolation :


Note :(In case of Long term isolations , transfer Isolation Certificates to Long term Isolation Register)
Name: Signature: Designation: Date : Time:
PERMIT TO WORK - HOT WORK No.:SSL/HW/

1 Specification of Work Mark All Boxes Y (Yes), N (No) or NA (Not Applicable) Valid for a shift-After This permit Renewal Required

Date of Application Applicant /Performing Authority Name Department


Location of Work Equipment Equipment No.

Description of work
Name of Persons Working
Note : ( Separate sheet to be attached in case of insufficient space above or change of persons during work)
Name of the working Agency
Tools & Equipments

2 Hazards Identified
Confined Space Tripping Hazard Excavation Collapse Toxic Gas Fumes Heavy Lifts Hazardous Substances

Mechanical/Electrica
l Sparks Hot surface Moving Machinery Fall from Height Steam Unguarded Opening

Slipping Hazards Ackward Access Flammable Material Hydrocarbon Area Noise Pressurised Pipework

Inadequate Lighting Dropped Objects Radioactive Source Static Electricity Vibration Pressurised Hose Failure

Simultaneous opn Gas cylinders Cutting set Electrocution Others


Note: Attach Annexure for more Hazards if space is less

3 Controls in Place
A Initial Gas Testing Oxygen Content Check Hose whip Check Continuous Gas Test Fire /Safety Watcher Portable Fire Extinguishers

Signs & Barriers Welding MC Checklist Gas Cutting Checklist Venting Fire Blanket/Screen Drains flushed & covered

Charged Fire Hose Additional Lighting Ear Protection Safe Access/Egress Lifting plan/Equipment MSDS Precautions

De-Pressurised Draining Secure Loose Objects Purging Extinguisher/Fire Tender Manual Handling equipment

Equipment Earthing
Simultaneous opn identified and Risk assessment carried out Caps on Gas Cylinders Flammables Removed Emergency preparedness
& Bonding

Flash Back Arrestor Gas Cylinder with trolley Intrintisically Safe Equipment Welder Apron

B Additional PPEs Standards - Helmets, Safety Shoes and Safety Goggles are mandatory

Leather Gloves Electrical Gloves Cotton Gloves PVC Gloves Heat Resistant Gloves

Maintenance Gloves Aluminium Suit Chemical Splash sheild Leg Guard Face Shield

Dust Mask/SCBA Arc Flash Suit Safety Harness Steam resistant gloves & Suit Tool Box Meeting

C Job safety Analysis HIRADeC are mandatory for all work associated with safety Systems HIRADeC & SWP/WI/SOP/SMP No:

D Additional Controls
Note : Sl No 1 to 3 Needs to be filled one day in advance from the Actual Work Execution Day and Annexures to be added if space is less anywhere

4 Isolation Required
Isolation Certificate Cert No. Confined Space Certificate Cert No. Excavation Certificate Cert No.

Height Work Certificate Cert No. High Voltage Switching certificate Cert No.

5 Authorised By SBU/Section Head Affected Area Authority Project In charge


I/we agree this work can proceedd provided all the above identified controls are in place and the precautions adheredd to by the work party
Name Signature Designation Date Time

Note : The Above Authorization is required for Identified Critical Jobs & for unplanned Emergency Jobs to be started on the same day

6 Site Atmosphere Test : (Mandatory for Critical Areas other than Confined Space`where possibility of Hydrocarbon or other gases is existant)
Initial Test by Authorised Gas Tester ;Continuous Monitoring by Performing Authority /Safety Watch

Test for: LEL O2 Other Peroidic tests to be carried out by AGT

Date Time LEL O2 Toxic CO Other Signature Date Time LEL O2 Toxic CO Other Signature

7 Issue

I the Shift Incharge / Area Authority ,declare that all hazards have been identified and all control measures are in I the Field Engineer/Operator confirms that all hazards identified and all control measures specified are in place
place and it is now safe for the work specified on this permit to be performed and is valid. and it is now safe to carry out the work specified on this permit.

From : hrs To : hrs From: hrs To: hrs

Name Signature Designation Date Time Name Signature Designation Date Time
I the Performing Authority, have read and understood the above conditions and precautions. I accept responsibility for carrying out the work as specified.I will ensure the persons under my control read,understand and comply with
these conditions and precautions.I will notify the Operation Shift Incharge / Area Authority on completion or interruption of this work.

Name (Print ) Signature Designation Date Time


8 Permit Re-Issue
Date:

From:

To:

Shift Incharge /Area


Authority (Issuer) - Name
Shift Incharge /Area
Authority (Issuer) - Sign

Performing Authority

9 Permit Sign of
PermitPerforming Authority I declare that all persons have been withdrawn and that all tools,plant and equipment
used have been removed and the site left in a safe clean and tidy condition.

The Work is complete The work is incomplete

Name (print) Signature Designation Date Time

I the Shift Incharge / Area Authority declare the work task is :- Complete Incomplete Isolations/Overrides can be removed:

Long term Isolations/Overrides required Remark for Long term Isolation :


Note :(In case of Long term isolations , transfer Isolation Certificates to Long term Isolation Register)
Name: Signature: Designation: Time : Date:
VEHICLE ENTRY PERMIT FOR HYDROCARBON AREA No.SSL/VE/

Mark all boxes Y (Yes), N (No) or NA (Not Applicable)

1 DRIVERS/VEHICLE DETAILS
Applicant:
Access Route:

Entry Purpose:

Vehicle type; (Crane/Forklift/Light vehicle/Bus/Tanker/Tractor/Digger/Buldozer etc.)


Drivers Licence: Vehicle Registration Number:

SITE SPEED LIMIT 20 Kmph NO PETROL ENGINE VEHICLE ALLOWED ON SITE

2 VEHICLE CHECKS (Minimum Requirement)


Full vehicle check required Spark arrestor fitted and in good condition: Work in hydrocarbon area of plant
No leaks in exhaust System Brakes and handbrake in working condition: Dangerous protrusions from vehicle:
Electrical wiring in good condition Lights and warning devices working:
Battery System and connections secure: oil Leaks from Engine/Transmission:

I the Authorised Person have checked the vehicle against the check list/standard and declare the vehicle meets the criteria for vehicle entry
Site Engineer/Associate Signature Designation Date Time

3 SITE SAFETY SYSTEMS

Safety Systems or Devices that may be obstructedd or compromised Details contingency plan or additional requirements

4 CONTROLS
Correct Fire Extinguisher in vehicle: Continuous Gas Test required Site road plan attached :
pre Entry Gas Test required: Periodic Gas Test required: Route barriers required and in place:
Driver/Crew Site Induction Carried out: Site escort required and available: Certificate of explosive in place:
Loose items on vehicle made secure: Driver aware of site speed limit; Valid Lifting Certificates in place:
Anti-Static bonding in place: Road worthiness : Driver aware of Site route hazards:

Additional Controls Required:

5 ATMOSPHERIC GAS TESTS (LEL)


Date Time Results Name Date Time Results Name

Date Time Results Name Date Time Results Name

6 ASSOCIATED PERMITS
Type Number Type Number Type Number

7 APPROVAL FOR VEHICLE ENTRY


I the SBU/Sectional Head approve entry for the vehicle identified as above of this permit,providing the controls are in place and precautions are adhered to

Name Signature Designation Date Time

8 SIGN ON
Vehicle driver/attendant: do you understand the requirements of this permit: Are you aware of and understand the site safety rules:
Name ( Driver/Attendant) Signature Designation Date Time

I am aware of my responsibilities as escort for the vehicle identified in Section 1 of this certificate
Name ( Site Engineer/Associate ) Signature Designation Date Time
9 WORK COMPLETE
I the Site Engineer/Associate confirm the following:
The work is complete: The work site is clean and tidy: All equipment has been removed: The vehicle has been removed:

Name Signature Designation Date Time

I the SBU/Sectional Head confirm all activities associated with this vehicle is complete and the site is clear

Name Signature Designation Date Time


ISOLATION CERTIFICATE No.:SSL/IC/

1 ISOLATION REQUEST Mark All Boxes Y (Yes), N (No) or NA (Not Applicable)

Plant/System to be isolated:

Equipment Number: Location:

Reason for Isolation:

Type of Isolation Required: Process / Mechanical: Electrical : Instrument:

Detail of associated equipments/items


isolated

Isolation Job Safety Analysis Required JSA No.: Drawings Attached:

P & ID/Electrical Drawing Numbers:

Name of Requester Signed: Date: Time: hrs.

2 ISOLATION CONTROL
HAZARDS and PRECAUTIONS

Hazards:

Precautions:

SAFETY SYSTEMS
What systems or devices will be
compromised:
Detail contingency plans:

HV ISOLATION
HV Isolation required: Certificate Number: Switching Plan/Procedure Number:

ASSOCIATED PERMITS/CERTIFICATES

Type Date Issued Description of work Date Cancelled Shift Incharge / Area Signature
Authority Name

APPROVAL TO ISOLATE

I the Operation Shift Incharge / Area Authority declare that the plant/equipment identified in Section 1 is safe and available for isolations to be made in accordance with SSL safe Work Practice on
Process/Mechanical and Electrical isolations.The isolations to be applied are listed in section 2a(Isolations record).
Name: Signature: Date: Time hrs

ISOLATION CONFIRMATION
I the Shift Incharge / Area Authority declare that the isolations listed in 2a (Isolation record sheet) are in place and tagged and the plant/equipment described in Section 1 is now in a safe condition
for work to commence.

Name: Signature: Date: Time: hrs

Isolation Record Sheet Number:

3. ISOLATION CERTIFICATE REGISTRATION BY PERMIT CONTROLER


Name: Signature: Date: Time: hrs

4 DE-ISOLATION CONTROL
Sanction to Test:I the Operation Shift Incharge / Area Authority authorise the temporary de-isolation for test purpose for -the equipment identified in the attached 2a (isolation record).

Name: Signed: Date: Time: hrs

De-Isolation:I the Performing Authority declare that the work carried out under this certificate is now complete and all concerned parties have informed and isolations associated with this
isolation certificate can now be removed.

Name: Signed: Date: Time: hrs

Return to Service:I the Shift Incharge / Area Authority declare that all concerned Certificates have been signed of and relevant work parties have been informed that work authorisation is
withdrawn and isolations under this certificate have been removed.The plan/equipment can be returned to normal service. This Isolation Certificate is now Cancelled.
All

Name: Signed: Date: Time: hrs

De-Registration:The permit register has now been updated to show that this Isolation Certificate has been cancelled and normal operations can safely proceed.

Name of PTW Controller: Signed: Date: Time: hrs

5 LONG TERM ISOLATION CONTROL


The Permits associated with this Isolation Certificate have now been cancelled but the Isolations must remain in place for the following reasons

Name: Signed: Date: Time: hrs

6 AUDIT RECORD
Audit has been carried out on this Isolation Certificate
Name: Signed: Date: Time: hrs

Title of Auditor:
ISOLATION RECORD SHEET No.SSL/IRS/

1 ISOLATION REQUEST
Plant/System to be
isolated
Isolation Certificate No

Equipment Number Location

2a ISOLATION RECORD

ELECTRICAL ISOLATIONS
SANCTION TO TEST
ISOLATION DE-ISOLATION
DE-ISOLATION RE-ISOLATION

Item Open/ Lock Name & Name & Name & Name &
No Tag No. Description Closed Locked no. Tagged Date Time Sign Date Time Sign Date Time Sign Date Time Sign

PROCESS / MECHANICAL ISOLATIONS


SANCTION TO TEST
ISOLATION DE-ISOLATION
DE-ISOLATION RE-ISOLATION

No Tag No. Item Open/ Locked Lock Tagged Date Time Name & Date Time Name & Date Time Name & Date Time Name &
Description Closed no. Sign Sign Sign Sign

INSTRUMENT ISOLATIONS
SANCTION TO TEST
ISOLATION DE-ISOLATION
DE-ISOLATION RE-ISOLATION
Item Open/ Lock Name & Name & Name & Name &
No Tag No. Description Closed Locked no. Tagged Date Time Sign Date Time Sign Date Time Sign Date Time Sign

Isolation Types: Process Mechanical Electrical Instrument


Isolation Requirements (Process & Blank Disconnect Spade Valve
Mechanical) Switch Open
Valve

Isolation Requirements (Process & Disconnect Earthed Fuse Removed Proved Dead
Mechanical)
PERSONNEL RECORD SHEET

Date Shift Agency Tool Box Permit


Talk done? No

Work to
be Done

Sr Name In Sign Lock Out Sign Height Remarks


No Time No Time Pass

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

I the Performing Authority certify that all persons involved in this work are aware about the SOP / SMP / SWP of the Job. Relevant Tool Box Talk has been done for the said work and all
personnel have been informed about the Hazards of the Job. All relevant precautions have been taken and relevant certificates taken for the said work and Personal Locks Locks are available
with all listed persons. For height jobs I have checked that no person involved is without Height Pass.
WORK-AT HEIGHT CERTIFICATE No.:SSL/WAH/

1 Specification of Work Mark All Boxes Y (Yes), N (No) or NA (Not Applicable) Valid for a shift-After This permit Renewal Required

Date of Application Applicant /Performing Authority Name Department

Location of Work Equipment Equipment No.

Description of work Associated Permit PTW No :

Name of Persons Working

Note : ( Separate sheet to be attached in case of insufficient space above or change of persons during work)
Name of the working Agency

Tools & Equipments

2 Hazards Identified
Fall from height Unguarded Opening Heavy Lifts Excavation Collapse Steam Improper placement of ladder

Fall of material Ackward Access Improper scaffold Mobile access platform Pressurised Pipework Temporary platform

Slipping Hazards Tripping Hazard Inadequate Lighting Simultaneous Opn Loose Objects at height Collapse of structure

Fragile roof Other Hazards

3 Controls in Place
A Height pass Safety harness with double lanyard Tested scaffold with tagging Hand rails Roof holes hard baricadded

Signs & Barriers Fall arrestors Safe Access/Egress Toe baords Vertical lifelines

MSDS Precautions Additional Lighting Outrggier incase of mobile scaffold Lifting plan/Equipment Horizontal lifeline

Drained Safety net Approach ladder Secure Loose Objects Emergency rescue plan

Simultaneous opn identified and Risk accessment done Cage for fixed ladder > 2.5 m Crawling ladder Supervsion

B Additional PPEs Standards - Helmets, Safety Shoes and Safety Goggles are mandatory

Leather Gloves Electrical Gloves Cotton Gloves PVC Gloves Heat Resistant Gloves

Maintenance Gloves Aluminium Suit Chemical Splash sheild Leg Guard Face Shield

Dust Mask/SCBA Ascendor/Dyscendor /Rope Crab Safety Harness Steam resistant gloves & Suit Tool Box Meeting

C Job safety Analysis HIRADeC are mandatory for all work associated with safety Systems HIRADeC & SWP/WI/SOP/SMP No:

D Additional Controls Others

4 Authorised By SBU / Sectional Head Project In Charge

I/we agree this work can proceed provided all the above identified controls are in place and the precautions adhered to by the work party

Name (Print) Signature Designation Date Time

5 Issue

I the Shift In charge,declare that all hazards have been identified and all control measures are in place and it is now safe for the I the Field Engineer/ Operator confirms that all hazards identified and all control measures specified are in place
work specified on this permit to be performed and is valid. and it is now safe to carry out the work specified on this permit.
From : To : From : To : hrs
hrs hrs hrs

Name ( Print) Signature Designation Date Time Name (Print) Signature Designation Date Time

I the performing Authority, have read and understood the above conditions and precautions. I accept responsibility for carrying out the work as specified.I will ensure the persons under my control read,understand and comply with these conditions
and precautions.I will notify the Area Authority on completion or interruption of this work.

Name (Print ) Signature Designation Date Time

6 Certificate Renewal
Date:

From:

To:

Shift Incharge / Area Authority

Receiving Authority

7 Certificate Sign of
Performing Authority: I declare that all persons have been withdrawn and that all tools,plant and equipment used have been
removed and the site left in a safe clean and tidy condition.

The Work is complete The Work is Incomplete

Name (print) Signature Designation Date Time

Shift In Charge: I declare the work/task is :- Complete Incomplete

All materials removed from site Housekeeping done

Name: Signature: Designation: Time : Date:


CONFINED SPACED ENTRY CERTIFICATE No.:SSL/CS/

1 Specification of Work Mark All Boxes Y (Yes), N (No) or NA(Not Applicable) Valid for a shift and it is restricted upto 6 pm only

Date of Application Applicant /Performing Authority Name Department


Location of Work Entry Description

Test for: LEL O2: Toxic: CO: Other: Test Equipment used:

Name of Persons Working


Note : ( Separate sheet to be attached in case of insufficient space above or change of persons during work)
Name of the working Agency

2 Isolation Required Process/Mechanical Isolations: Permit. No. Electrical/Instrument Isolation: Permit. No.

3 Hazards Identified for Entry


Confined Space: Ackward Access Excavation Collapse Toxic Gas Fumes Noise: Hazardous Substances

Dropped Objects: Slipping Hazard: Tripping Hazard: Hydrocarbon : Heat: Airborne Particles e.g. Dust:
:
Entrapment: Engulfment: Flammable Material Adverse Weather: Traffic: Inadequate Isolations:

Inadequate Lighting Unguarded Opening: Radioactive Source Simultaneous Opn Other Hazards:

4 Controls in Place For Entry


Safety Watcher Rescue Equipment Available: Safe Access/Egress: Gas Detector Callibrater: Breathing Apparatus Available :

Signs & Barriers Walky Talky Available & Tested: Safety Harness & lifeline: Isolation in Place & verified: Inhibits/Overrides Required

De Pressurised: Draining: Purging: Venting: Excavation Supports in Place:

Ventilation Provided Additional Lighting in Place: Face Mask with Filter : Ear Protection: Chemical suit:

Additional PPES Fire service Informed: Ambulance Informed 24 volt lighting source Emergency preparedness

Exhaust & Blower Manhole opened Emergency exit Additional control required

5 Authorisation for the Initial Testing and Inspection: SBU/ Sectional Head Project In Charge

The work to test and inspect the confined space can proceed provided all the above identified controls are in place and precautions being adhered to.
Note: This activity must be carried out in accordance with the guideline for confined space entry

Name Signature Designation Date Time

6 Issue for Initial Testing and Inspection:

I the Shift Incharge / Area Authority declare that all controls as specified above are in place.The Authorised
I the Authorised Gas Tester, have read and understand the above conditions and precautions specified.I accept
Gas Tester can, in accordance with the controls and precautions, test the space and if conditions meet the responsibility for carryig out atmospheric testing and inspection of the nominated confined space.I will ensure the
approved criteria,they can enter the space for the purpose of inspecting to establish the suitability of the
space for work to be performed. persons under my control read and understand an comply with these conditions and precautions.

Name Date: Name: Date:

Signature: Time: Signature: Time:

Designation: Designation:

7 Initial Atmosphere /Gas Test Results: (Successive Atmospheric /Gas Tests are to be carried out as indicated below)
Agent Entry without BA Entry with BA Date Time Result Name Signature

O2 20%-21% 16.5% - 20%

LEL Less than 1% 1%-10%

Toxic TLV STEL Value

CO 50 ppm Max 200ppm Max

Other

8 Permits and HIRADeC Associated With this Entry permit and Additional Controls

Cross Referenced Permits No. No. No. No.

HIRADeC No: HIRADeC are Mandatory for all work associated with Confined Space Entry

Ventilation Required: Entry with BA Only: Entry with Airline and Hood: Toolbox Talk:

9 Issue for Entry to Carry out Work:


I the Performing Authority for the work to be undertaken inside the confined space,have read and understand the
I the Shift In Charge, declare that all entry controls are in place and JSA/HIRA recommendations applied and the conditions and precautions specified above and the JSA/HIRA.I will abide by these and will ensure the persons
work identified on the Permits listed above can proceed,subject to the following gas testing programme being under my control adhere to these conditions.
applied:

Continuous Gas Test: Intermittent Gas Test: Frequency:

Name: Date: Name: Date:


Signature: Time: Signature: Time:

Designation: Designation:
10 Certificate Renewal
Date:

From(Time):

To(Time):

Shift In Charge

Performing Authority

11 Certificate Closure
Performing Authority:
I declare that all personnel have been withdrawn, Permits closure and that all tools and equipment used have been removed from the confined space associated with this certificate and the area left
in a safe clean and tidy condition.

Thw Work is Complete: The Work is Incomplete: The status of the work being:

Name: Signature: Designation: Date: Time:

Shift incharge/Area Authority:This permit is now void and no further entry is permitted

Name: Signature: Designation: Date: Time:


HIGH VOLTAGE SWITCHING CERTIFICATE ( ≥ 6.6 KV )

Permit No. SSL/EL/ SOP/WI No.

1 ISOLATION Mark All Boxes Yes,No or N/A(Not Applicable)


Equipment covered by this permit:
Tag Numbers:

LOTO Key No
Switching Programme Attached: Isolation: De-isolation:

LT ISOLATION CERTIFICATE ASSOCIATED WITH THIS HIGH VOLTAGE SWITCHING CERTIFICATE


Permit Nos. SSL/ SSL/ SSL/ SSL/
Name of Persons Working:

REQUEST FOR ISOLATION SWITCHING PROGRAM PREPARED BY SWITCHING PROGRAM CHECKED BY


Name Name Name

Signed Signed Signed

Time Time Time


Date Date Date

Sanction to test may be requested by Permit Recipient:


A SANCTION TO TEST MUST BE AUTHORISED BY
Name Signed THE SECTIONAL HEAD / SBU HEAD AS
IDENTIFIED ON THE ASSOCIATED PERMIT
Time Date
Authorised By : Name Signed :

AFFECTED AREA AUTHORITY


Name Sign Area

ISOLATION PERFORMED BY ISOLATION AUTHORITY


Name Dicipline

Signed Time Date

ISOLATION CHECKED BY AREA AUTHORITY / SHIFT INCHARGE


Name Dicipline

Signed Time Date

I the Performing Authority declare that the above equipment preparations and precautions have been adhered to. I will abide by the conditions of the attached
SOP/SMP/SWP/WI

Name

Signed Time Date

Work Complete: All men/materials/tools removed: Earthing Equipment Removed:

2 DE-ISOLATION
REQUEST FOR DE-ISOLATION -PERFORMING AUTHORITY
Name

Signed Time Date


DE-ISOLATION APPROVAL : SHIFT INCHARGE / AREA AUTHORITY
Name

Signed Time Date

DE-ISOLATION COMPLETE : ISOLATION AUTHORITY


Name

Signed Time Date

I CONFIRM DE-ISOLATION COMPLETE -THE EQUIPMENT CAN BE RESTORED TO NORMAL OPERATING CONDITION
Name

Signed Time Date


EXCAVATION CERTIFICATE No.SSL/EP/

Mark all boxes Y (Yes), N (No) or NA (Not Applicable)

Date of issue Time: Expiry date: Time:

1 SPECIFICATION OF EXCAVATION
Applicant: Designation Company

Excavation by: Company

Area/Location:

Description of Work:

Name of Persons Working

Extent or Excavation: Width: Length: Depth

Tools/Equipment to be used:

2 HAZARDS:

Confined Space Tripping Hazard Excavation Collapse Toxic Gas Fumes Heavy Lifts Hazardous Substance

High Pressure jet Simultaneous Opn Unguarded Opening: Working at Height: Steam: Pressurised Pipework:

Slipping Hazard: Awkward access: Flammable materials Hydrocarbon area: Noise: Pressurised Hose failure:

Inadequate Lighting Dropped Object: Radioactive source: Static electricity: Vibration: Electrical hazard

Other Hazards:

3 CONTROLS
Drawings are attached to certificates: Underground service drawing checked: Safety barriers required/in place:

work/site area Gas Test required: Driver/crew Site Induction carried out: Shoring required/available at the site:

Access/Escape Route(s) identified: Valid lifting Certified in place: Driver aware of site route hazards:

Additional lighting available /in place: Fire /Emergency Equipment available: Additional PPE available:

Simultaneous Opn carried out: Additional Controls Required:

Electrical Systems in Excavation Area: Are drawings available to show location/depth of cables: Can the Systems be safely isolated:

I confirm the isolations are in place: Signature: Date: Time:

Mechanical Maint Systems in Excavation Area: Are drawings available to show location/depth of pipework etc. Can the Systems be safely isolated:

I confirm the isolations are in place: Signature: Date: Time:

Process/Utility Systems in Excavation Area: Are drawings available to show location/depth of facilities: Can the Systems be safely isolated:

I confirm the isolations are in place: Signature: Date: Time:

Instrumentation Equipment in Excavation Area: Are drawings available to show location/depth of equipment: Can the Systems be safely isolated:

I confirm the isolations are in place: Signature: Date: Time:

IT & Telecom Equipment in Excavation Area: Are drawings available to show location/depth of equipment: Can the Systems be safely isolated:

I confirm the isolations are in place: Signature: Date: Time:

I declare that the above checks have been carried out,the relevant isolation and controls are in place ready for the excavation work identified as above.

Name of Performing Authority Signature Designation Date: Time:

4 ASSOCIATED PERMITS/CERTIFICATES:
Type Number Type Number Type Number

5 AUTHORISATION BY Sectional Head: Project Head: Shift Incharge / Area Authority :


I/We agree the activities identified as above of this certificate can proceed providing the controls are in place and precautions are adhered to and executed through the appropriate and approved Permit to work

Name Signature Designation Date Time

6 ISSUE
I,the Shift In Charge declare that all the hazards have been identified and all controls are in place and it is now safe for the sxavation /penetration work to proceed

Name Signature Designation Date Time

7 Certificate RE ISSUE
Date:

From:

To:

Shift Incharge / Area Authority

Performing Authority

8 WORK COMPLETE

I the Shift In Charge confirm all activities associated with this excavation work are complete.
The excavation is Open and barriers erected aroud this excavation site: The excavation is Closed and the work site clean and tidy:

Name Signature Designation Date Time