Pressure Testing Permit

1. Permit Request

I, the Nass Contracting, apply for a Pressure Test Permit for the area detailed below in compliance with the requirements of NC-
001-C2-HSE-064-R00. I have personally viewed the work area, assessed the potential hazards arising from the task, and have
implemented the mitigating actions stated below. I shall ensure all Task Performers are aware of these requirements and are
competent to complete the task safely.
Note: I am aware that any changes to the task stated in this permit, the work area or working conditions will require a new PTW to
be requested.

Name Date

Designation Time

Work Area

Task

Type of Pressure Test

Hydraulic – Pressure bar; Duration At Full Pressure Days/Hours

Pneumatic - Pressure bar; Duration At Full Pressure Days/Hours

Precautions And Requirements Implemented * (M) = Mandatory Requirement

Emergency Procedure / Contact (M)

Toolbox Talk (M) Venerable Items Removed

Restricted Personnel Access (M)

Safety Relief Valve Fitted (M)
Adequate Drain Plugs

Equipment Calibration Certs (M)

Display Warning Signage (M)
Blank Plugs Fitted

Display Permit In Area (M) PPE As Stated In JSEA (M) Reducing Valve (As Applicable)

Erect Barriers Around Test Area (M) Lock Out/Tag Out (As Applicable) Additional Lighting

JSEA Attached To Permit (M)

All Valves Closed At Test Ends Other (State)

2. Approval – Issuing Authority

I, the Nass Contracting, is duly satisfied that all hazards have been identified with necessary precautions and controls implemented, as required
under NC-001-C2-HSE-064-R00, and work can commence on date/time below:

Signed Contractor
Approved Person Date
(if applicable)

Designation Time

Signed HSE
Date
Approved Person(M)

Designation Time

3. Permit Issuing

The maximum duration of this permit is 7 Days, PROVIDING NO CHANGE TO TASK OR CONDITIONS HAS OCCURRED.
The Time on and Time off must be completed and initialed by the Issuing Authority at the end/commencing of shift.

Shift Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 (Max)

Day ON: ON: ON: ON: ON: ON: ON:

Night OFF: OFF: OFF: OFF: OFF: OFF: OFF:

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4. Permit Clearance

This section is only signed on task completion/suspension or on completion of 7 working days.

I, the Permit Requestor, have completed/suspended the Task specified in this PTW, and have personally checked to ensure the area is safe, secure,
a standard of housekeeping has been maintained and no further work is required

Signature Date & Time

5. Permit Cancellation

I, the NC Issuing Authority is satisfied this permit can be cancelled. A copy will be retained on file in the HSE office for reference.

Signature Date & Time

Reset Print

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