PERMIT TO WORK

PTW No : A3 -
NO WORK IS SO URGENT THAT WE CANNOT TAKE TIME TO DO IT SAFELY
SECTION 1 – WORK DESCRIPTION (BY PERFORMING PARTY) HOT WORK CONFINED SPACE ENTRY

AREA CLASSIFICATIONS CONDITIONS TO BE IMPLEMENTED BY RECEIVING AUTHORITY/WORK LEADER

APPLICANT'S NAME :............................................................ DEPARTMENT / COMPANY :.................................................................
Zone 0 H2S TYPE OF HOT WORK ENTRY ATMOSPHERE
STAFF NO. . :.................................................. LOCATION/FACILITY :..................................................................................................... Safe
Zone 1 ! WELDING ! GAS MONITORING ! FIRST ENTRY USING SCBA OR ! HEALTH DECLARATION FORM
Zone 2 Radioactive ! FLAME CUTTING ! CONTINUOUS
EQUIPMENT NO. :...................................................................................... AREA :.....................................................................................
AIRLINE SET ! CONTINUOUS GAS MONITORING
! OPEN FLAME ! PERIODIC EVERY __________ HRS ! ENTRANTS ARE CSE CERTIFIED ! REVALIDATION OF GAS CHECK
ASSIGNED ASSEMBLY POINT : ............................................................ NUMBER OF PEOPLE WORKING UNDER PERMIT : ............................................................ ! GRINDING ! FIRE EXTINGUISHER ! ENTRANTS BRIEFED OF RISK BY EVERY .............................HOURS

WORK DESCRIPTION : ...........................................................................................................................................................................................................................................................................

! DRILLING ! FIRE BLANKET WORK LEADER ! CONTINUOUS VENTILATION
! POWER BRUSHING ! FIRE RETARDENT SCREEN ! TYPE OF COMMUNICATION USED ! EXTRA LOW VOLTAGE LIGHTING
......................................................................................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................................................................................... ! HOT TAPPING ! FIRE HOSE ON STANDBY ! LIFELINE (50V maximum)
! HOT TAPPING PLAN ATTACHED ! SPARK ARRESTOR ! WALKIE TALKIE ! LOCATE MOBILE EQUIPMENT AWAY
! PYROPHORIC ! COVER SEWER/DRAIN/SUMP ! WHISTLE/HORN FROM MANHOLE
SECTION 2 - HAZARDS / HAZARDOUS ACTIVITIES ! SPARK PRODUCING ! LOCATE SPARK PRODUCING EQUIPMENT ! ENTRY STATUS LOG ! CONFINED SPACE ENTRY CHECKLIST
! FLAMMABLE RELEASE AWAY FROM SEWER/TRENCH ! MAXIMUM NO OF PERSONS ATTACHED
! Gas & Fume ! Hot surface ! Radiography ! Battery Operated / Electrical Tools ! Lack of Oxygen ! VEHICLE ENTRY ! REMOVE FLAMMABLE MATERIAL ALLOWED __________ PERSON ! RESCUE & EVACUATION PLAN
! Volatile Liquid Under Pressure ! Electrical ! Crane ! Electronic Device ! Other ! VEHICLE INSPECTION CERT. ! OTHERS :...................................................... ! RESCUE EQUIPMENT AT SITE ATTACHED
! Chemical / Phyroporic ! Working at height ! Interlock Bypass ! Generator / Compressor ........................................................... ! OTHERS :................................................... ! OTHERS :...................................................
! PHOTO TAKING
! H2S ! Scaffolding ! Hydrojetting ! Rotating Equipment ...........................................................
! OTHERS :.........................................
! Steam ! Lifting ! Pressure Test ! Pneumatic Tools ...........................................................
Special Precautions .............................................................................................................. Special Precautions ..............................................................................................................
! Dust powder ! Excavation ! Saw /cold cut ! Noise ...........................................................
................................................................................................................................................. .................................................................................................................................................
................................................................................................................................................. .................................................................................................................................................
SECTION 3 - WORKSITE PREPARATION / PRECAUTIONS Fire Watch Names Safety Watch / Standby Person Names
Name Date Name Date Name Date Name Date
! Equipment isolation ! Flushed with water ! Running water on
! Equipment / line blinded off ! Lock out and tag out ! Contact area/panel operator on completion
! Valve chain-locked open / close ! Area roped off ! Ensure Equipment Is Decontaminated
! Equipment/line depressured ! Warning sign ! Consideration of Adjacent Jobs
! Equipment/line drained ! Scaffold erected and safe to be used ! Hand Tools only
! N2 purged / steam out ! Secure tools/materials against falling ! Others: ................................................................. GAS TEST RESULTS
! Contact area/panel operator before work starts ............................................................................
Special Precautions :............................................................................................................................................................................................................................................................................... Tests Standard Initial Result
.................................................................................................................................................................................................................................................................................................................... Oxygen 20% to 20.9%
AGT Name :................................................. Date :.........................................
Combustible < 1% LEL

SECTION 4 -PERSONAL PROTECTIVE EQUIPMENT Signature :..................................................... Time :........................................

Toxic < 50% PEL

Mandatory Respiratory Protection Eye, Face & Body Protection Fall Protection ! Hand Protection ! Personal O2 Monitor
! Helmet ! Half Mask Respirator ! Goggles ! Full Body Harness ! Cotton Gloves ! Personal Dosimeter/Film HOT WORK APPROVAL CONFINED SPACE ENTRY APPROVAL
! Safety shoes ! Full Face Respirator ! Face Shield ! Fall Arrest ! Leather Gloves Badge/Survey Meter I have personally checked that all control measures to prevent hazardous conditions have I have personally checked that all control measures to prevent hazardous conditions have
! Safety glass ! SCBA ! Welding Mask ! Rubber Gloves Others been put in place. been put in place.
! Approved Coverall ! Airline Set ! Chemical Suit Hearing Protection ! Chemical Gloves ! Life jacket / vest Approving Authority Department Designation Date CSE Approving Authority Department Designation Date
! Dust mask ! Chemical Boot ! Ear Plug Personal Monitoring Equipment ! Seat belt
! Disposable Suit ! Ear Muff ! H2S Meter ........................................... Name :............................................... Name :...............................................
! Personal Distress Unit ...........................................
Signature :......................................... Signature :.........................................
...........................................

SECTION 5 - SUPPORTING CERTIFICATES / DOCUMENT SECTION 9 – REVALIDATION FOR NIGHT WORK

! ELECTRICAL ISOLATION - Cert. No....................................... ! RADIATION - Cert. No...................................................... ! SKETCHES DRAWING/P&ID DATE BY RECEIVING AUTHORITY BY APPROVING AUTHORITY
! LIMIT of ELECT. ACCESS - Cert. No........................................ ! ROAD OBSTRUCTION - Cert. No................................... ! LIFTING DATA
! PHYSICAL ISOLATION - Cert. No............................................ ! JHA – Doc. No. …………………………………………. ! TOOLS INSPECTION CHECKLIST Name :................................................................ Name :........................................................................
! SAFETY SYSTEM BYPASS - Cert. No...................................... ! RELATED PTW No. …………………………………….. ! JOB METHOD STATEMENT Signature :.......................................................... Signature :..................................................................
! LIFTING CERTIFICATE – Cert. No ………………………….. ! CERTIFICATE OF FITNESS FOR MACHINERY ! OTHER.......................................................................... Date :........................Time :................................ Date :..........................Time :.................................
............................................................................................
............................................................................................

SECTION 6 – PERMIT TO WORK ENDORSED & REVIEW SECTION 7 – PERMIT PROPOSAL SECTION 10 - HAND BACK
I have personally checked the area and equipment to be worked on and satisfied the work requested can be carried out
I ensure to carry out the work safely as per this PTW conditions ! Work Completed and all associated Permits closed.
safely
! Work continue
BY RECEIVING AUTHORITY BY HSE BY PERFORMING PARTY ! Incomplete hand-back (Equipment status, reason for hand-back, etc.) ....................................................................................................................................................................
................................................................................................................................................................... ................................................................................................................
Name :..................................................................................... ................................................................................................................................................................... ................................................................................................................
Name :................................................................................ Name :....................................................................................
................................................................................................................................................................... ................................................................................................................
Signature :........................................................................... Signature :...............................................................................
Signature :......................................................................... ................................................................................................................................................................... ................................................................................................................
Date :............................. Time :.......................................... Company / Dept. :...................................................................
Date :....................... Time :..............................................
Date :................................. Time :..........................................

SECTION 8 – PERMIT TO WORK AUTHORIZATION (BY APPROVING AUTHORITY)

I authorized the work to commence subject to the conditions on this PTW. RECEIVING AUTHORITY ACCEPTED BY APPROVING AUTHORITY
Name :......................................................................................
PTW Valid From D M Y TIME Signature :................................................................................ Name :....................................................................... Date :.............................. Name :........................................................................ Date :..............................
PTW Valid Until D M Y TIME Date :............................. Time :..............................................
Signature :................................................................. Time :............................. Signature :.................................................................. Time :.............................

Always follow ZeTo Rules no. 1. STOP WORK AND EVACUATE AREA ON HEARING OF EMERGENCY ALARM
Work with a valid work permit (PTW) required by the job.
Distribution - Original: Displayed at Worksite Copy No. 2: PTW Station Copy No. 2: Receiving Authority
 Pre Job Checklist
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Area Classification
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Zone 0 That part of a hazardous area in which a flammable atmosphere is continuously present or present for a long period.
PTW)Joint)Site)Visit)conducted)/)‘PTW)Joint)Site)Visit”)telah)dibuat)
PTW&and&JHA&requirements&have&been&verified&and&communicated&to&all&and&understood&/&Segala)keperluan)di)dalam)PTW)dan)JHA)
Zone 1 That part of a hazardous area in which a flammable atmosphere is likely to occur in normal operation.
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Hazards&from&the&ac)vity&has&been&shared&and&understood&/&Segala)bahaya)yang)terdapat)di)dalam)akEviE)telah)diterangkan)dan) That part of a hazardous area in which a flammable atmosphere is not likely to occur in normal operation and if it occurs
difahami& Zone 2
will exist only for a short period.
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Conducted&by&RA/PP&(Name&and&Signature):&&&& & &Date&/&Time&:&&&

& & &&&&&&&&&&&&&&&&&& &Company&&:&&&

Gas Test Results

O2 LEL Toxic AGT
Date Time AGT Name
(20 - 20.9%) (<1%) (<50% PEL) Signature

Note : If there is an emergency declared in the plant all permits /certificates are canceled.