GENERAL WORK PERMIT F.

HSE-48/R01
IJIN KERJA UMUM 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 : Validation Period : Time & Date: ……………………………..to………………………………….

Periode Masa Berlaku 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
Equipment depressurised, drained and purged. Safety Helmet
Bejana tekan, buangan dan pelepasan. Safety Glasses
Equipment mechanical isolated (tagged and locked) Goggles
Peralatan mekanikal diberi tanda (tagged dan locked) Face shield

Equipment electrically isolated (tagged and locked) Safety shoes

Peralatan elektrik diberi tanda (tagged dan locked) Rubber boots
Work gloves
Warning signs posted at work point.
Tanda peringatan ditempat kerja. Hearing protection
Safety Harness
Gas test done-flammeble,poisonous & oxygent depletion. Work vests
Test gas-mudah terbakar, beracun & pengurangan oksigen.
SCBA
Result/Hasil :…….. Respirator
Others..................

DANGER NOTICES AND ADDITIONAL

SAFETY EQUIPMENT REQUIRED :
Tanda-tanda bahaya dan tambahan
peralatan safety yang diperlukan

AUTHORISATION FOR WORK PERMIT 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 WORK 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