MECHANICAL ISOLATION CERTIFICATE CERT NO.

00000

SECTION 1 - ISOLATION PLAN

Date
Facility

Location
Associated PTW

W/O No.

Date Raised Related Isolation Cert No.

Equipment Tag Equipment Name Reference documents (marked up) Notes

Plant & Instrumentation Diagram (P&ID) 1) For Boundary Isolations, all PTW associated with the isolation
Single Line Diagram (SLD) shall be stated in this certificate.
Operating / Maintenance Procedures (OP / MP) 2) De-isolation for testing shall be included in the Isolation Plan.
Isolation Description Sequential Name Signature Date
Isolation? Requested by Performing Authority
Yes Prepared by Isolation Authority
No Approved by Area Authority

SECTION 2 - ISOLATION LIST

1. Position : "O" = open "C" = closed "D" = disconnected 2. Please circle either "ISOLATION", "DE-ISOLATION" or "DE-ISOLATION FOR TESTING"
ISOLATION / DE-ISOLATION / ISOLATION / DE-ISOLATION /
ISOLATION DE-ISOLATION
DE-ISOLATION FOR TESTING DE-ISOLATION FOR TESTING
Name Sign. Date Time Name Sign. Date Time Name Sign. Date Time Name Sign. Date Time
Permit Co-ordinator:
Isolation/ de-isolation does not conflict with any other activities.
Seq. ISOLATION POINT Lock No. Position Sign. Date Time Position Sign. Date Time Position Sign. Date Time Position Sign. Date Time

Name Sign. Date Time Name Sign. Date Time Name Sign. Date Time Name Sign. Date Time
Area Authority:
I have verified the isolation/ de-isolation of the above equipment.
Performing Authority:
I have witnessed and am satisfied with the isolation/ de-isolation.
Associated Electrical Isolation Certificate No.

Section 3 - RETAINED ISOLATION

The above isolations shall remain in place for an extended period and > 7 days Name Signature Date
Start Date
Any isolation > 90 days shall be documented via Management of Change (MoC) process. Application for Implementation
Justification(s): Requested by Performing Authority
Approved by Area Authority
Acknowledged by Permit Coordinator
Application for De-isolation
Requested by Performing Authority
Approved by Area Authority
Nominated Isolation Authority
Acknowledged by Permit Coordinator

SECTION 4 - CERTIFICATE CLOSURE

Name Sign. Date Time Copies
Area Authority: 1st Worksite
I hereby declare the isolations related to this certificate has been reinstated. 2nd Permit Coordinator
This certificate is now closed. 3rd OIM Office