PSP PERMIT TO WORK FORM
Date of issue : 18-May-2025 No : 4
Terminal Site Location
PS Pipeline KVDT Test
Form Type Technician Description of work
KVDT test1 test
From Until Risk level
18-May-2025 24-May-2025 Medium
JMS
eptw [Link]
JMS
eptw [Link]
Appendix - Associated Certificate
Hot Work
No Status Validity From Validity To
HOT001 AGT Acknowledge 18-May-2025 18-May-2025 Active
PERMIT HOLDER
Name Company [Link] Staffs
test test PS Pipeline 1
Staff List
test
Special Permission
test test test 18/05/2025
PRODUCT INVOLVED WORKING AREA
Class Demarcation
Fire Extinguisher
Use of Warning Signs
Others
Engineer
Engineering Advice Required
WORKING AREA
Permit Supervisor is aware of the safety instructions as in the:
Terminal safety manual
Permit to Work and associated certificates
Name Date And Time
test1
Precautions for the work (in addition to those overleaf, and stated in associated certificates)
I certify that I have fully considered the implications of the work in line with the responsibilities detailed in the
permit to work procedure and that the above precautions are adequate for the work to be carried out provided
that the precautions are established and maintained.
Engineer Name Date/Time
Operation Manager Name Date/Time
Permit Authorized By
HSSE VERIFIER Permit Issuer(PI) LEAD PERMIT ISSUER (LPI)
Verified all the HSSE requirement Authorised for execution without Authorised for execution only in
in place including JMS and JSA additional certificates accordance with attached
HSSE Verifier Name PI Name certificate
LPI Name
Date/Time Date/Time
Date/Time
From
From
Until
Until
Operational Measures: To be signed by Operation Executive (for MPP) or Controller (for KVDT)
Shut down system operational
Fire protection system operational
Automatic fire protection system operational
Any Other Measure
Permit validity (where work is going to last more than the duration of a day)
Permit issuer & Permit Holder confirm by signing that the precautions required to work safely have been
complied with prior to starting work each day or work period. At the close of each day, the Permit Issuer & Permit
Holder sign to confirm that the area has been left in a safe condition (although it is still not an operational area,
i.e. it has been handed back) and that all staff have left the site.
Hot Work Certificate No : 4
(To be completed only by authorised persons)
Specify location within terminal OPERATIONAL INFORMATION
test I have to checked the work place and the area directly
surrounding it within 15 meter and;
Specify likely ignition sources
. It is free of flammable material
test
. Sewer and drainer system, and other low lying areas are
protected against sparks
. The work area is defined with barriers/signs
. Additional fire fighting materials are present and ready to
use
. A continuous gas detector is installed
. Safety officer to Safety Supervisor
PTW Holder Validity From
test test 18-May-2025
Company AGT
PS Pipeline test test
Note : Operator can be the AGT or a depot staff member who review the workplace
Gas Test
. Once before commencement of the work
. Test while work is in progress, at specified frequency
The following working area has been tested for
tes
flammable gases/vapours
Gas test performed
I confirm that I have tested for gas and/or oxygen and that the result are within the specified acceptance levels,
and the measured concertation of explosive gasses/vapours is zero % LEL
O2 C O2 H2 S LEL Approved Date Time A G T Name
1 1 1 1 18-May-2025 test test
Engineer LPI Hot Work Certificate is certificate
and permit to work are withdrawn:
I certify that I have reviewed the Hot Work Certificate is described Permit Holder Name
proposed work and I am satisfied in the permit to work is allowed
test test
that it is adequately described on between:
the permit to work and that the Name Permit Holder Date/Time
precautions detailed are adequate
and clearly defined
Date/Time Permit Holder Reason
Name
From
Date/Time LPI Name
18-May-2025
LPI Date/Time
LPI Reason
