Permit To Work

Revision Date Description

00 12th May 2020 Remove Lightning Arrestor 22KV TBM – Intake TL22KV

Document Revision and Approval

Proc. No: KLIC_HSE_SP-001/FM-004

FM. Title: Permit To Work (PTW)

Any Alarm, Alert, Gas Release, Evacuation or other Emergency Suspends / Cancels this permit. To Restart Contact Permit
PTW No:
Authorizer
Activity Category: A B C D [A]: Access Permit; [B]: Work Permit; [C]: PTW plus S/Permit; [D]: PTW plus Work Pack. Plant:

Valid From :12 th May 2020 Standard Word Statement (S WS): WO No :

Valid To: 12th May 2020 Standa rd Wo rk Descrip tion : PTW CR OSS REFER ENC ES:

Main tenan ce Section s : [M] [E] [IC] [C]

Suppo rt Se ction s : [ M] [E] [IC] [C]

2 Remove Lightning Arrestor 22KV TBM – Intake
TL22KV
Developer Vanglong
No. of Work Orders linked: [ 1 ] HSE Engineer
Work Order Type: [PM] [CM] [CBM] [Other]

Operation Testing Required: [N] [Y]

Modifier
Maintenance. Testing Required:
Bruce Eng
[N] [Y]
PlanningLocation:
Engineer
1. WORK ACTIVITY EQUIPMENT No:

Maintenance Order activities: WC Duration Maintenance Rem arks:

1. Remove All Lightning

Reviewer Arrestor
Woo Sung Min22KV Form TBM To Intake
Operation Site
Manager

Maintenance
Reviewer Song Dong Seok
Manager
President & Plant
Approver Young Park TRA No.

Manager RTRA/TBT No.

LOTO: Box No. / Ke y No. (NN/NNN)

For additional operations check WO

Name Title Date Signature
MAINTENANCE (Permit Originator): I certify that this PTW is prepared in accordance with Procedure & printed after verifying systematic approvals.

Name: MAINTENANCE Signature: Date: Time:

Uncontrolled, if printed * Refer latest version in the server / SAP * If required, print both the sides *
FM No: KLIC_HSE_SP-001/FM-004 Rev: 00
 Permit To Work
2. ADDITIONAL (SUPPLEMENTARY) PERMITS / CERTIFICATES ( cross referenced perm its and certificates shall be kept displayed together) CR: Cross Ref .

Perm its Permit No. YES NO CR Cer tificates Cer tifica te No. YES NO CR
Hot Work Perm it Isolation Certificate
Diving Perm it Scaffolding Certificate
Confined Space Entry/Work Perm it Radiation Certificate
Excavation Perm it HV Isolation Certificate
Working at Height Perm it Simulation Certificate
Heavy Machinery Movement Perm it Test Certificate

3. APPROVAL & ACCEPTANCE:

SAFETY: I declare that this task is safe. I hereby approve this task.(Note: Safety approval is not required for Access Perm it, A-Category)

Name: SAFETY Signature: Date Time:

OPERATION (Permit Issuer, PI) Supervisor/SCE/Engineer: I declare that Technical System is secured. I hereby approve this task.
Name: OPERATION Signature: Date Time:

MAINTENANCE (Permit Acceptor, PA): I declare that I have checked isolations, LOTO & precautions personally and found OK.

Name: MAINTENANCE Signature: Date Time:

4. PERMIT CONTROL (INSPECTION & SUPERVISION):

Section Name-signature date/time Observation

5. PTW EXTENSIONS:
Perm it validity extension-I: Reason with Requestors ' Name, Signature & Date: New Validity (PI: Name, Sig. Date): Perm it Acceptor (Name, Sig, date):

Perm it validity extension-II: Reason with Requestors ' Name, Signature & Date: New Validity (PI: Name, Sig. Date): Perm it Acceptor (Name, Sig, date):

6. TEMPORARY SUSPENSION:
M AIN T EN ANCE (PA): I de cla re tha t al l wo rks a re cea sed OPERAT ION (PI): PER MIT SU SPENDED OPERAT ION (PI): PER MIT R ESUMED
PA Name/Signature/Date/Time: PI Name/Signature/Date/Time: PI Name/Signature/Date/Time:

7. PERMIT CLOSURE & CANCELLATION

MAINTENANCE (Permit Acceptor): All work associated with this perm it is completed & housekeeping done.

Name: Date Time:

MAINTENANCE Signature:
OPERAT ION (Permit Issuer): I hereby declare that I am satisfied with completion requirements & clos e this permit.

Name: Date Time:

OPERATION Signature:

FM No: KLIC_HSE_SP-001/FM-004 Rev: 00 Date: 04 Jul 2017