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    FRM-3028 (Energy Isolation Permit) Oke

    Uploaded by

    rizki
    This document is a permit for isolating energy and hot work from PT. SIWICS METAKOMPRESI PRATAMA. It contains information such as the permit number, valid dates, location, contractor, work description, safety inspections, certifications, electrical/mechanical isolation procedures, approvals and signatures from the site authority, area authority and performing authority. Upon work completion, signatures are required to confirm the work is accepted and safety barriers have been restored.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    FRM-3028 (Energy Isolation Permit) Oke

    Uploaded by

    rizki
    300 views1 page
    This document is a permit for isolating energy and hot work from PT. SIWICS METAKOMPRESI PRATAMA. It contains information such as the permit number, valid dates, location, contractor, work description, safety inspections, certifications, electrical/mechanical isolation procedures, approvals and signatures from the site authority, area authority and performing authority. Upon work completion, signatures are required to confirm the work is accepted and safety barriers have been restored.

    Original Description:

    SIK isolasi energi

    Original Title

    FRM-3028 (Energy Isolation Permit)Oke

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    This document is a permit for isolating energy and hot work from PT. SIWICS METAKOMPRESI PRATAMA. It contains information such as the permit number, valid dates, location, contractor, work description, safety inspections, certifications, electrical/mechanical isolation procedures, approvals and signatures from the site authority, area authority and performing authority. Upon work completion, signatures are required to confirm the work is accepted and safety barriers have been restored.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    300 views1 page

    FRM-3028 (Energy Isolation Permit) Oke

    Uploaded by

    rizki
    This document is a permit for isolating energy and hot work from PT. SIWICS METAKOMPRESI PRATAMA. It contains information such as the permit number, valid dates, location, contractor, work description, safety inspections, certifications, electrical/mechanical isolation procedures, approvals and signatures from the site authority, area authority and performing authority. Upon work completion, signatures are required to confirm the work is accepted and safety barriers have been restored.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    IZIN ISOLASI ENERGI

    IZIN KERJA PANAS


    PT. SIWICS METAKOMPRESI PRATAMA
    HOTISOLATION
    ENERGY WORK PERMIT
    PERMIT

    No. Izin Kerja : Izin berlaku mulai : Hingga :


    Permit No. Valid from Until
    Tanggal : Lokasi (Unit/Area/Bangunan) : Peralatan yang digunakan :
    Date Location ( Unit/Area/Building) Equipment / Tools used
    Kontraktor :
    Contractor

    Uraian Pekerjaan :
    Description of work

    PEMERIKSAAN KESELAMATAN DITEMPAT KERJA / SAFETY INSPECTION AT WORKING AREA


    Dilakukan oleh Pengawas Lapangan dan Pengawas Pelaksana / Conducted by Site Authority and Performing Authority
    Alat telah dibersihkan dengan baik Toolbox Meeting/Safety Talk Ventilasi telah dilakukan sepenuhnya
    Equipment properly flushed Conducted Toolbox/Safety Talk Throughly ventilated has been done
    Alat /Bejana disekat dengan baik Alat Pelindung Diri (APD) Wajib Safeguard telah ada ditempat kerja
    Unit/Equipment has been isolated PPE Mandatory Safeguard has been available at worksite
    Rambu Peringatan terpasang Jalan Masuk/Keluar telah disiapkan Penguncian/tanda peringatan telah
    Warning Sign is in place Proper access has been prepared disiapkan
    Alur listrik telah diamankan Peralatan aman untuk digunakan Lock Out/Tag Out has been prepared
    Electrical hazard identified Safe tools to be used
    Prosedur Darurat diketahui Pencegahan Pencemaran SOP/SWP disosialisasikan dan dimengerti
    Emergency Procedure acknowledge Conducted spill prevention SOP/SWP has been socialize and understood
    Koordinasi dengan Dept terkait Bahan beracun telah ditiadakan
    Coordniation with related Dept Toxic material has been removed
    Lain-lain
    Others
    PEMERIKSAAN SERTIFIKAT KETERANGAN / CONFIRMATION CLEARANCE CERTIFICATE
    Oleh Pengawas Daerah / By Area Authority
    Analisa Keselamatan Kerja Isolasi Listrik / Mekanik
    JSA and Risk Assessment Electrical/Mechanical Isolation
    Serah Terima Area Lain-lain
    Hand Over Area Others
    Alat Pelindung Diri (APD) tambahan
    Additional PPE Requirement
    ISOLASI LISTRIK / MEKANIS
    Electrical / Mechanical Isolation

    Nama Pengawas bagian Listrik/Mekanis Pelaksanaan Isolasi Pelaksanaan menghidupkan lagi


    Name of Electrical/Mechanical Supervisor Isolatian Performer Energies/Connect Performer

    Tandatangan Pengawas Waktu Isolasi Waktu menghidupkan kembali


    Supervisor Sign Isolation Time Energies/connect Time

    CATATAN KHUSUS DARI PENGAWAS DAERAH


    Special Notifications from Area Authority
    Pengawas Lapangan koordinasi dengan departemen terkait untuk mendapatkan
    bantuan atau jaminan bahwa pekerjaan bisa dilakukan dengan aman / Site Authority shall
    coordination with related department to get assistance or warranty that the work can be safety done
    Saya telah mengerti kondisi yang tertera di surat izin ini dan akan menjelaskan kepada regu kerja sebagaimana mestinya dan akan
    meninggalkan tempat kerja dalam keadaan bersih dan aman / I understand the conditions laid down by this permit and will brief the work crew
    accordingly and will leave the site clean and safe condition

    Pengawas Pelaksana/Performing Authority : Nama/Name : Tandatangan/Sign :_ Wakt u/Time :_


    Petugas Keselamatan/Safety Personnel : Nama/Name :_ Tandatangan/Sign : Waktu/Time:_
    Saya telah meninjau kembali seluruh persiapan dan cara kerja dan memberi izin kerja untuk dikeluarkan / I have reviewed and all
    precautions and methods of work and authorized the permit to be issued

    Pengawas Lapangan / Site Authority : Nama / Name:_ Tandatangan/Sign:_ Waktu/Time :_


    Pekerjaan dapat dimulai bila persyaratan tersebut diatas telah dipenuhi / Work may commence providing all the above conditions have been meet

    Pengawas Daerah / Area Authority : Nama/Name :_ Tandatangan/Sign :_ Waktu/Time :_


    PERPANJANGAN IZIN KERJA / Permit Extension Permit ini akan diperpanjang / This permit
    Perpanjangan izin kerja harus melampirkan Analisa Keselamatan Kerja dan Identifikasi may be extend
    Bahaya / Job Safety Analysis and Hazard Identification have been attachment for permit extension

    Izin diperpanjang mulai :_ Hingga : Pengawas Daerah / Area Authority


    This permit is extended from Until Nama dan Tandatangan / Name & Sign
    PENYELESAIAN PEKERJAAN / Work Completion
    Saya pastikan bahwa pekerjaan ini telah selesai dan dapat diterima, seluruh pagar pengaman dan tanda-tanda keselamatan telah
    dikembalikan pada kondisi semula / I have confirmed tha the work has been completed and accepted, all safety barriers and signs have been restored

    Pengawas Pelaksana/Performing Authority Nama/Name: Tandatangan/Sign: Waktu/Time:_


    Pengawas Lapangan/Site Authority: Nama/Name:_ Tandatangan/Sign:_ Waktu/Time :_
    Distribusi : Putih (Pengawas Lapangan), Kuning (Pengawas Pelaksana), Biru (Arsip)
    Distibution : White (Site Authority), Yellow (Performing Authority), Blue (File)
    SIWICS-FRM-3028, 1 Mei 2014, Rev. 0

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