MANUAL HSE

Seguridad, Salud Ocupacional

y Medio Ambiente Anexo 3
Procedimiento HSE 2.21
Rev 00, Junio 2012
Pagina 1 de 1

Autorización de Empleado Adicional

Additional Employee Clearance Attachment 3 Page ___ of ___

EmployeeSystem Authorized

Project Name / Location: : CVPUE / Arequipa / A6CV Lock Box Number:

Clearance Number (enter number from associated LOTO Clearance)

LOTO Requested By Work to be performed

(Print Authorized Employees' names) (Brief description of work or testing to be done)
Authorized Employee(s)

LOTO Issued To
LOTO Released By
(Authorized Employee print and sign name and list Lock Date / Time Date / Time
(Authorized Employee sign name)
#, Home and Work Phone Numbers)

L#

H W

L#

H W
L#

H W

L#

H W

L#

H W

L#

H W

L#

H W

L#

H W

L#

H
L#

H W

L#

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