PERMIT TO WORK WITH COSHH MATERIALS

PROJECT:

PTW No:FT\CHP\

1.0 : TASK SUPERVISOR:

AREA/LOCATION

TYPE OF WORK

DATE/TIME:

NAME OF SUPERVISOR:

SEC/DEPT

2.0 : PRECAUTION CHECKLIST:

YES NO

MSDS available on workplace

Facemask/ respirator required for the activity provided as
per MSDS
Suitable hand gloves for the activity provided as per MSDS
Suitable coveralls for the activity provided as per MSDS

N/A

YES NO N/A
Fire extinguishers in operable
condition provided
No simultaneous operation
(Hotwork.) in the same area
Adequate ventilation to minimize
smoke buildup
Area isolated by warning tapes & warning
signs from other works

Fire watch available

Adequate illumination (natural and artificial)

Any other precaution (to specify in detail):

3.1: SUPERVIOSR / TASK IN-CHARGE:

3.2: STORE INCHARGE

3.3 HSE REPRESENTATIVE

PERMIT APPLICANT
I have read and understood the scope of
the work, the condition of the site, the
actions required and the special
requirement for safe execution of the Job.
I shall abide by this during the execution of
the Job.

PERMIT AUTHORIZER
I certify that all the chemicals and quantity requested
have been Issued

PERMIT ISSUER
I have verified the area and chemicals
involved and declare that it is safe for work to
proceed.

MATERIAL REQUESTED :

QUANTITY ISSUED :

VALID UPTO:

QUANTITY REQUESTED :

NAME:

DATE & TIME

NAME:

DATE & TIME

DATE & TIME

SIGNATURE:

SIGNATURE:

SIGNATURE:

NAME:

4.0 CLOSE OUT

4.1: SUPERVIOSR / TASK IN-CHARGE:

4.2: STORE INCHARGE

4.3 HSE REPRESENTATIVE

PERMIT APPLICANT
I have checked the area and declare the
area is free from all fire hazards. The
permit is closed. All COSHH substances
have been returned to store and empty
cans have been disposed of.

PERMIT AUTHORIZER

PERMIT ISSUER
I have verified the area and chemicals
involved and declare that all COSHH items
have been removed and safely disposed of or
returned to stores. This permit is closed.

I certify that all the chemicals issued have been returned

to store or disposed of accordingly.

NAME:
NAME:

DATE & TIME

SIGNATURE:

NAME:

DATE & TIME

SIGNATURE:

Note :- To be returned to the HSE representative after the completion of work or for closure

MNE/OHS/P22/F01 - 12/2011 Rev 0

SIGNATURE:

DATE & TIME