Nama Pekerjaan : No.

No. SPK :
PT. MULTIMAS NABATI ASAHAN IJIN KERJA AMAN F/MNASRG-EHS-17-034
SERANG SAFE WORK PERMIT Hal : 1 Rev : 2
Diatas permukaan tanah / Above ground level
Diatas Permukaan Air/Above the water surface
SECTION 1
LEMBAR ASLI WARNA PUTIH BERADA DIAREA KERJA

Diberikan kepada Dept/PT Tgl-Bulan-Tahun Validasi

Issued to Dept/ PT Date-Month-Year Jam Start
Lokasi yang tepat Daerah Waktu s/d Time End
SETELAH IJIN KERJA DISAHKAN

Exactly location Area Time to Paraf Pemohon Izin

Jumlah Pekerja Deskripsi Pekerjaan Sign Head Dept PT. MNA

Total Manpower Actual job

Pekerjaan Panas : Yes Mengelas/Welding Pembakaran/Burning Menggosok/brushing, sandblasting Lainnya

Hot work No Lampu potong/Gas cutting torch Penyambungan/Riveting/Jointing Pemancangan/Concrete pile / other
Menggerinda/Grinding Memukul/Use pneumatic hammer Penggalian, pengerukan potensi percikan/ ............
Mengebor/Drilling Penghancur/Chippers Excavation, dredging with potential spark ............
Memanaskan/Heating Non Explossion proof Equipment Menggerinda potong/Cutting wheel

Pekerjaan Dingin : Yes Pengecatan/ Painting Pekerjaan sipil logam/metal civil work Kebersihan dan kebun/Cleaning and gardening
PLACED IN WORK AREA AFTER SAFE WORK PERMIT

Cold Work No Pengecoran/Civil casting Penimbunan/landfill Pemasangan perancah/Install scaffolding

WHITE COLOR OF THIS ORIGINAL SHEET MUST BE

Kerja sipil non logam Penggalian/Excavation Lainnya/ Other:

Non metal civil work
SECTION 2

Pekerjaan Di Ketinggian: Yes Konstruksi Beam/Beam construction Bekerja diatas Piperack/Piping on piperack Di lantai/On the platform or grating
Working at Height No Ereksi tangki/Erection Tank Di scaffolding/On the scaffolding Dengan Gondola/By Gondola
APPROVED

Lainnya/ Other:

Ruang Terbatas : Yes Potential Risk: Kekurangan Oksigen/Lack of oxygen Kebakaran/Fire Keracunan/poisoning Lainnya/other:
Confined space No Type of work: Bekerja didalam tanki/Tank work Memasuki Manhole Memasuki Pit Lainnya/other:

Kegiatan Angkat/angkut: Yes Forklift Pedestal Crane Tower Crane Crawler Crane Lainnya/other:
Lifting/transporting activities No Pick-up/trailler Mobile Crane Chainblock/Hoist Handlift

Kegiatan lain resiko Tinggi: Yes Extremely hazardous material handling Activity with radioactive Lainnya/other:
Other high risk activities No Chemical handling Supply power testing
SALINAN WARNA MERAH MUDA: ARSIP EHS DEPT /
SALINAN WARNA HIJAU: PROJECT / PLANT HEAD

DAFTAR CEK - KERJA PANAS Status Checking DAFTAR CEK - KERJA DI KETINGGIAN Status Checking DAFTAR CEK-RUANG TERBATAS Status Checking
Checklist of Hot Work A NA Yes No Checklist of working at height A NA Yes No Checklist of confined space A NA Yes No
1) Peralatan telah di inspeksi dan kondisi normal 1) Perancah & Tangga telah di inspeksi 1) Pengosongan & bilas N2
Equipments has inpected and normal condition Scaffolder / ladder has inspected Emptying & N2 blanketing
2) Aman dari percikan api/ penyalaan 2) Tersedia scaffolder & Inspektor Scaffolding 2) Sirkulasi udara segar
Safe of spark/ ignition Available Scaffolder & Inspector Scaffolder Fresh air blowing
P2K3L

3) Bahan potensi terbakar diamankan 3) Terpasang pijakan,handrail/pengaman 3) Penguncian/tutup flange

Potential fire material was removed Flatform, Handrail/safety guard was installed. Lock out/blind flange
4) Fire blanket telah terpasang 4) Telah dipasang static line 4) Kunci dan tanda di manhole
Fire blanket was installed properly Installed proper static line Lock out&tag out manhole
5) Tidak terjadi kebocoran bahan 5) Pekerja Ketinggian Berkompeten 5) Radio dan lampu DC
berpotensi kebakaran Worker working at heighy has competen Available Radio & DC lighting
There are not material leakage 6) Terpasang safety net 6) Tersedia SCBA
6) Instalasi telah dikosongkan, p = 0 Safety net was installed SCBA is available
Line installation was emptying, p = 0 7) Petugas rescue tersedia 7) Pekerja Berkompeten & Personil pemantau
SECTION 3

7) N2 blangketing telah dilakukan

COPY GREEN COLOR: PROJECT, PLANT HEAD

Rescue person are available Worker Confined Space & Standby person
COPY PINK COLOR: COPY EHS DEPT / EHS

N2 blangketing was done 8) Equipment : ………………………………………………………………... 8) Atmosphere check:

8) LOTO System telah diterapkan - O2 content: 19.5 - 21%
Implemented LOTO System DAFTAR CEK - ANGKAT/ANGKUT Status Checking - LEL = 0
9) Sarana pemadam tersedia cukup Checklist of lifting/transporting A NA Yes No - H2S Content = 0
COMMITTEE

Fire extinguishers are available 1) SIO/SIM Operator/driver - Other gas = 0

10) Petugas pengawas api tersedia
Fire watch are available
11) Equipment : …………………………………………………………………
DAFTAR CEK - KERJA DINGIN
Checklist of cold work
1) Peralatan kerja laik pakai
Good/safe equipments
2) Proteksi area kerja
OLEH PEMOHON IZIN KEPADA PEMBERI IZIN. PENUTUPAN
PERMIT SETELAH SELESAI PEKERJAAN HARI YANG SAMA
VALIDASI PERMIT SETELAH ISTRIRAHATPADA FORM ASLI
Driver license was available 9) Equipment : …………………………………………………………
2) Sertifikat inspeksi peralatan Pekerjaan Lainnya (Lembur, dsb) / Other Activity (overtime, etc) :
Equipment certificates
Status Checking 3) Sling dan clamp aman
A NA Yes No Safe sling and clamp usage
4) Tersedia tali pandu muatan
Rope guider was available
5) Ada Riggers yang kompeten

Barricading/clearing area Available Competent Riggers

3) Operator/Fitter kompeten 6) Proteksi area kerja
Operators/Fitters are competent Barricading/clearing area
4) Equipment : ………………………………………………………………… 7) Equipment : ………………………………………………………………...
SECTION 4

APD/PPE: Safety Helmet Face Shield Dust Mask Rubber Gloves Safety Boot Full Body harness
Welding Helmet Ear Plug/Ear Muff SCBA/Airline Set Chemical Gloves Coverall/Safety Vest Safety Line/net
Safety Glasess Half Face Respirator Cotton Gloves Heavy Duty Gloves Apron Pelampung/Life Vest
Safety Google Full Face Respirator Leather Gloves Safety Shoes Chemical Suit Other:

Diperlukan cek atmosfir regular: Yes Date Time % LEL % O2 % H2S Others Gas Safe (Y/N) Remark:
Required regularly atmosphere check No
SECTION 5

Uji atmosfir oleh:

Atmospheric test by

ID Peralatan:
VALIDTATE PERMIT FROM ORIGINAL SHEET AFTER

Equipment ID
BREAK BY PREPARED PERSON TO APPROVED

Dengan sebenarnya telah Disiapkan oleh: Disetujui oleh: Diverifikasi oleh : Temuan :
It had been Prepared by: Approved by: Verified by: Finding :
SECTION 6
PERSON

Pemohon Izin Head Dept EHS Dept

PT. MNA Serang PT. MNA Serang
Penutupan ijin kerja disetujui oleh:
Deklarasi Penutupan Ijin Kerja: Yes No Closing work permit was approved by
SECTION 7

Declaration of Closing Work permit 1) Peralatan kerja telah disimpan/ diamankan

Equipment antd Tools have been stored safely
Selesai Pekerjaan/ Finished work 2) Area telah bersih dari sampah dan scrap Pemohon Izin Head Dept PT. MNA Serang
The area was cleaned from garbage and scrap