Judul Dokumen: Revisi: 00

Fomulir HSE
Dokumen No.: Halaman:
HSE/FORM-44 1 of 1

EXCAVATION PERMIT
IJIN PENGGALIAN
NO. …23….

DATE : _______17 JUNI 2023__________ LOCATION : _GARDEN_____________

TANGGAL LOKASI
PURPOSE : ___PENGGANTIAN PIPA _______________________________________________
MAKSUD

The area detailed by sketch below has been thoroughly searched by way of facility drawings.
Lokasi penggalian yang dijelaskan di bawah telah diperiksa secara melalui gambar denah fasilitas.

The following excavation hazards are noted:

Berikut bahaya-bahaya yang terdapat pada pekerjaan penggalian:

1. Adanya kabel listrik yang melintang

2. Adanya pipa salauran yang lain
3
4

Precautions required prior to excavation are:

Tindakan pencegahan sebelum penggalian:

1. Limited excavation digging (x)

Pengamanan daerah penggalian
2. Hand shovel digging required (x)
Alat penggali tangan disediakan
3. Spotter to identify hazards (x )
Mengidentifikasi potensi bahaya
4. Electrical or other isolations ( x)
Isolasi peralatan listrik/lainnya
5. Others ( x)
Lain-lain
Tick (X) applicable boxes
Beri tanda (X)

SKETCH OF LOCATION DETAILS

RINCIAN LOKASI PENGGALIAN

ELECTRICAL/ MAINTENANCE SUPERVISOR : Dewa made kumaradana

EXCAVATION SUPERVISOR : Jemian

FACILITY SUPERVISOR : Nyoman Trisnawan

SUMMARY OF WORK COMPLETED

PENYELESAIAN PEKERJAAN

SIGN-OFF SIGNATURE : _________________________________________________

Tanda Tangan