PRESSURE WORK PERMIT F.

HSE-47/R01
IJIN KERJA TEKANAN PERMIT NUMBER:
This permit may be applied maximum 1 day work with revalidated 12 hourly (Shift Changed)
Surat Ijin Kerja ini dapat digunakan maksimal 1 hari kerja dengan revalidasi setiap 12 jam (pergantian shift)

Date & Time :

Rig & Location : Standby/Rescue Personnel
Tgl & Waktu
Issued To. (Dikeluarkan ke) Specific Work Location (Spesifik Lokasi Kerja) Validation Period 1 Validation Period 2

Department: Revalidation Period : Time & Date: ……………………….. to……………………………..

Periode Pengesahan Ulang Jam Tgl.

Detailed description of work to be

performed:
Penjelasan detail dari pekerjaan yang
akan dilaksanakan
JOB REQUIREMENT (PERSYARATAN PEKERJAAN)
YES N/A CONTROLS COMMENTS CHECK ALL PPE
REQUIRED
PRESSURING/PEMBERIAN TEKANAN
Safety Helmet
Signs Posted
Safety Glasses
Tanda-tanda Larangan
Non Essential Personnel Cleared Goggles
Bebas dari orang yang tidak berkepentingan. Face shield
Communications Established
Melakukan komunikasi. Safety shoes
High Pressure Lines Secured. Rubber boots
Kondisi aman pada Jaringan Tekanan Tinggi.
Work gloves
Instrumentation Operable
Peratan yang dioperasikan. Hearing protection
DEPRESSURISING/PELEPASAN Safety Harness
Work vests
Issolate Mechanical Power.
Pengaman sumber listrik. SCBA
Open valves and Bleed system Respirator
Buka katup dan Sistim pengeluaran
Others..................
Chek Gauges
Periksa Meteran.

DANGER NOTICES AND ADDITIONAL

SAFETY EQUIPMENT REQUIRED :
Tanda-tanda bahaya dan tambahan
peralatan safety yang diperlukan
AUTHORISATION FOR WORK TO BEGIN / Yang berwenang mengijinkan dimulainya pekerjaan
I hereby certify that it is safe to work on the following equipment.
Dengan ini saya menyatakan pekerjaan aman untuk dikerjakan sesuai dengan pelengkapannya
Permit Applicant Work Permit Authority Client Representative Controlling/Monitoring
Yang Memohon Yang Memberi Ijin Perwakilan Klien

………………………………….. …………………………………. …………………………………. ………………………………….

Name & Position Name & Position Name & Position Name & Position

REVALIDATION PERMIT
Pengesahan ulang Ijin Kerja

Permit Applicant Work Permit Authority Client Representative Controlling/Monitoring

Revalidation Period
Shift Signature, Name & Signature, Name & Signature, Name & Signature, Name &
(Time & Date: From …..to………..
Position Position Position Position

AUTHORISATION FOR PERMIT CLEARANCE / Yang berwenang untuk pemeriksaan ijin kerja
I hereby declare that the work for which this Permit was issued is now:
Dengan ini saya menyatakan pekerjaan yang tertera di ijin kerja ini, saat ini dalam status:
Permit Applicant Controlling/Monitoring
Work Permit Authority Client Representative COMPLETED/Telah selesai;
Signature, Name & Signature, Name &
Signature, Name & Position Signature, Name & Position Time & Date:…………………….
Position Position

SUSPENDED/Ditunda ;
Time & Date:……………………..

CANCELLED/Dibatalkan;
Time & Date:………………………

Copy: 1. White - Applicant 2.Pink - Permit Board Worksite 3. Blue - Area Authority 4. Yellow - File