Izin Kerja : _________/HSSE/ /ITM________________ Izin Kerja : _________/HSSE/ /ITM________________ Tgl/Jam masuk & Keluar: ______________________________________ Tgl/Jam masuk & Keluar: ______________________________________ Pelaksana Pekerjaan : PT ____________________________________ Pelaksana Pekerjaan : PT ____________________________________ Pimpinan Pelaksana : ______________________________________ Pimpinan Pelaksana : ______________________________________ Pengawas Pekerjaan : ______________________________________ Pengawas Pekerjaan : ______________________________________ Jumlah Pekerja : _______Orang Jumlah Pekerja : _______Orang Pekerjaan Hari Ini : ______________________________________ Pekerjaan Hari Ini : ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ Lokasi Pekerjaan : ______________________________________ Lokasi Pekerjaan : ______________________________________ ______________________________________ : ______________________________________ ______________________________________ ______________________________________ Gas Safety Gas Safety Security Ahli Teknik Safety Inspector Security Ahli Teknik Safety Inspector Inspector Inspector