Blanket

SITE PERMIT TO WORK PTW NO.

Reg. no.

1. WORK PERMIT IDENTIFICATION AND DESCRIPTION - by Permit Requester

Scaffold
Cold Electrical Hazard Manbasket Crane Lift Grating Removal
Fenced Areas
Hot Work at Height Hazardous Material Lock out / Tag out
Confined Space Road Interruption Night Work Pressure Test Pre-Commissioning
Associated Documents - by Permit Requester

Method Statement JSA Competent pers. info MSDS P&I Grating Removal
Lifting Plan Undergr Map/Draw Scaffold Study Hazardous Material Plot Plan Other

Performer : Receiver:

Area/location:
Description of the Work :

JOB / MEANS - by Permit Requester

Crane Motor Generator Drill Forklift Gas Cylinder Truck/Vehicle-mixer vacuum
Excavator Elevating Platform Welding Machine Hand Tools Torch/ Free flames Electrical hand tools
Pneumatic Tools Ladder Slings / Chain Compressor Thermal treatment Chemicals
Vessel/Sewer Chain Block/Tir fort Scaffolding Man Basket Concrete pump Bridge Crane
NDT Source Other :
POTENTIAL HAZARD IDENTIFICATION - by Permit Requester
Collapse Falling Object High Noise Hit by Moving Object Crash Moving Object Harmful Contact
Fall from Height Suspended Load High Tension Contact Sharp Contact Silver Projection Breathing Danger
Cables/Housekeeping Drown Asphyxia Radiation Burn Possible H2S,CO,N2,HCL
Fire/Explosion Pressure/Vacuum Temperature Chemicals Previous Danger Subst. Hydrocarbons
GENERAL PRECAUTIONS - by Permit requester
Mandatory PPE Special Overall C, T Rubber Gloves/Boot Iso. Electical gloves Face Shield / Hook Restrict Access/Barricade
Goggles Dust Mask FP Filter Mask Ear Muffs Harnesses (2 ropes) Guarded insulated tool
Man Watching Ventilation/Aspiration Air Supplier/Respirator Ear plugs Lifejacket Depressurized/Drained
Entry Log Rescue Plan No Work top/down Additional lighting Alternative route LOTO - Blind
Safety rope Radio/Air Horn Life Rope Winch / tripod Maintain Wet Low Voltage 24 V
Soil Class/Sloping Shoring/Reinforce Isolate the Area Hand Excavation Shields Steamed/water/inert flush
Signs Night Warning Water ready Sewer/drain isolated Grounding equipment Gas Detector
Fire Watching Extinguisher Ready Antistatic/spark Scaffolding Process (P, T) Safe Spark Containment
GAS TEST AIR TEST Electric. safe No Work above/below ROAD interruption SCUBA apparatus
Other:

COMPLEMENTARY FORMS TO BE FILLED BEFORE TO ISSUE WORK PERMIT (NEXT PAGE)

Lock out / Tag out ✘

Gas / Air Test Road Closure Other Other

Validity Request From Date : Time : Until Time :

Requester (Name & Surname) Signature Date

2. WORK PERMIT REVIEW - by Permit Reviewer

Validity Given From Date : Time : Until Time :

Other Cooperation needed : No Yes Coordination - Cooperation note:

ARTSON, TECHNICAL REVIEWER (Name &

Surname)
Signature Date

ARTSON, HSE REVIEWER (Name & Surname)

Signature Date

3. WORK PERMIT APPROVAL - by Permit Issuer

Concur that the requirement to proceed cover the job, I certify that I'm aware of the work as defined is to be carried out as per Paragraph 1 and 2, as stated after Reviewer signs (if foreseen). I
issue the work permit after complementary measures requested are taken and all the measures related to the work to be done are in place.

ISSUER (Name & Surname) Signature Date

4. WORK PERMIT EXECUTION - by Permit Receiver

I accept the job site supervision as per paragraph 1,2,3 and any Complementary Permit and complying with requirements & precautions needed for safe work

RECEIVER (Name & Surname) Signature Date

5. REVALIDATION - for different shift

I confirm that the conditions of the permit have not changed since initiation. Work may continue over the next period

Issuer From Date : Time : Until Date : Time :

Issuer From Date : Time : Until Date : Time :

6. WORK CLOSURE
We have inspected the work and accept that the work has been completed in accordance with the work scope and this permit's requirements - The site has been left in housekeeping and safe
conditions related to the work done - All inhibited system for this PTW can be reverted to normal after this section (see next page)

Receiver Issuer Date : Time :

Permit closed out on Reviewer Date :

 Permit Extension
Blanket PTW NO. Reg. No.: TEN/AEL……………………

DATE TIME FROM TIME TO Signature Issuer Signature Receiver Remarks

NB: PTW Valid from Monday to Saturday

 SITE PERMIT TO WORK COMPLEMENTARY FORMS WO NO. 26706788 Reg. no.

by Competent Authorised Persons

A. ENERGY ISOLATION / TAG-OUT LOCK-OUT

I request the isolation of the system / equipment below described.

Equipment / System :

Area / Location :

Validity Request From Date : Time : Until Date : Time :

ISSUER (Name & Surname) Signature Date

ISOLATION DESCRIPTION - ENERGY - by Competent Authorized Person

Pressure /
Electrical Streams /
Temperatur Other:
Energy Chemicals
e
Double
ISOLATION DESCRIPTION - METHOD
Blinds
System System
Block and
Electrical Flange /
Drained
Physical line Purged
Switch off Bleed
Disconnecti Slip Blind
Other:
disconnection and lock
ADDITIONAL PRECAUTION TAKEN, INCLUDING TYPE OF on
LOCKOUT - TAGOUT DEVICES:
ISOLATION DEVICES LOCATION LOCK Nr DATE OF INSTALLATION

Attachment
s: I certify that the system / equipment above identified has been isolated as described and work requested can be performed
Only after section 6 is completed the system can be re-energized, ensuring that no other PTW are ongoing under this isolation

Competent Authorised Person Signature Date

B. GAS / AIR TEST

I request the Gas / Air Test of the system / equipment below described.

Equipment / System :

Area / Location :

Air (O2) LEL H2S COx: Other:

ISSUER (Name & Surname) Signature Date

TEST DESCRIPTION - by Competent Authorized Person

Ever
Gas Test Condition: Initial Continuous y
Date dd/mm/yy Time / hour
O2% 19.5 - 22 LEL % < 10%
Reading
H2S < 5 ppm Cox
hrs:
Others
AGT Initials

Attachment
s: Competent person is responsible for Gas Test equipment proper function, inspection, maintenance, etc as per manufacture instruction.
The Initial Gas Test must be carried out within 1 hour prior to work commencing. The Authorized Gas Tester (AGT) shall carry out all test

Authorized Person (Name & Surname): Signature Date

C. ROAD CLOSURE
I request the Road Closure / Limitation as below described.

Area / Location :

Validity Request From Date : Time : Until Date : Time :

Partial
Total Day Total Night Partial Day Short Time
Supervised Night
Signs Night Signs Barrier Other:
all time
ISSUER (Name & Surname) Signature Date

Alternative
ROAD CLOSURE ACCEPTANCE AND COORDINATION - by Competent Authorized Person
Communication HSE Staff
Route Note
to all Informed
Note: needed

Authorized Person (Name & Surname): Signature Date

Discrepanc D. WORK STOPPAGE

y from Other Situation Normalized - Work Restart

PTW Note Date Time Name Signature Date Time Issuer Signature