COLD / GENERAL WORK PERMIT

Long Duration □ Yes □ No

Work Permit No: _______________

Department Section Isolation Certificate No. Equipment to be worked on:

A. Validity of Permit (Date & Time) From To Equip. ID Work Location

B. Job Description: Requestor Name Contact No.

Tick in the Appropriate Box No. of Persons working under the scope of this permit
Isolation Tag No.
C. Type of Isolation / Arrangements Yes No N/A Details & Precautions Electrical / Valve
1. Process Isolation - System Fully Depressurized State (Tank /
Line)

2. Electrical Isolation
3. Working at Height
4. Radiation Isolation, If any
5. Instrument Isolation (Power / Pnematic) if any
6. Artificial Lighting Arrangement
7. Competent Supervsior / Chargehand at site
8. Safe Access / Egress
9. Adequate Mechanical Ventilation (i.e Fans, Exhaust)
if required
10. Traffic Management, If any
D. PPE Requirement:
□ Safety Helmets □ Safety Shoe □ Safety Goggles □ Face Shield □ Ear Plug □ Ear Muff □ Cotton Gloves □ Leather Gloves □ Chemical / PVC Gloves □ Safety Harness □ Safety Net
□ Cover all □ Fall Arrest □ Dust Mask □ Half Mask □ Gas Monitor □ Self-Contained Breathing Appratus □ Air Line □ Rescue Rope □ Fire Extinguisher □ Fire Blancket
□ Edge Protection (Hand Rail) □ Step Ladder □ Mobile Scaffolding □ Fixed Scaffolding □ Manlift □ Boom Loader □ Mobile Crane □ Barrications & Signages □ Chemical Suit
□ Others, Please Mention, ________________________________________________________________________________________________________________

E. Gas Test □ Required □ Not Required

Date & Time ………………………………. Gas Test Result Details & Precautions Accepted Level
Oxygen % 19.5 - 22.5
Combustible LEL % 0
Toxic Gas H2S ppm 8
Toxic Gas - CO ppm 10

Name of Gas Tester: ………………………………………………………………………………………… Signature of Gas Tester: …………………………………………………………………………………………

F. If the Job is carried out by Contractor, Name of Contracting Company ……………………………………………………………………………………………….... Contact Person: ……………………………………………………………….
G. Permission granted for work to commence
Job preparations & precautions were well explained in TBT, SOP & JSA, etc., to the Receiver & their System is FULLY SAFE to start the Job: I understand the Job explanation, preparation, precautions
Team to be taken while executing & will inform the issuing
authority about any discrepancies.
Permit Requestor : Permit Issuer (Process Owner): Permit Receiver Name:
Name: ……………………………………………………………………………………... Name: …………………………………………………………………………... …………………………………………………………...
Signature: ………………………………………………………………………………… Signature: …………..………………………………………………………… Signature: ...…………………………………………………………………
Date & Time: …………………………………………………………………………... Date & Time: …...………………………………………………………… Date & Time: ...……………………………………………………………

Remarks:

H. Confirmation from HSE at

the time of Permit Issue:
Safety Officer Vijayakumar Signature: Date & Time:
Name :

H. Permission granted for the TRIAL RUN

Job preparations & precautions were well explained in TBT, SOP & JSA, etc., to the Receiver & their System is FULLY SAFE for the Trial Run: I understand the Job explanation, preparation, precautions
Team to be taken while executing & will inform the issuing
authority about any discrepancies.
Permit Requestor : Permit Issuer (Process Owner): Permit Receiver :
Name: ……………………………………………………………………………………... Name: ……………………………………………………………………………………... Name: .......…………………………………………………………………...
Signature: ………………………………………………………………………………… Signature: ………………………………………………………………………………… Signature: ...…………………………………………………………………
Date & Time: …………………………………………………………………………... Date & Time: …………………………………………………………………………… Date & Time: ...……………………………………………………………

I. Permit Handover ⃝ Between Issuers ⃝ Between Requestors ⃝ Between Receivers ⃝ Between Fire Watch
Time:
Reliever Name
Reliever Signaturer
Reliever Mobile No.
J. Extension of Validity
Date Valid up to

Requestor Name: Permit Issuer (Process Owner): Name Permit Receiver Name
Requestor Sign: Permit Issuer (Process Owner): Sign Permit Receiver Sign
K. Completion of work L. Site / Equipment Acceptance
Work completed, housekeeping done & checked. ⃝ Permit Cancelled ⃝ Permit Closed
Date & Time:…………………………………………… Reason for Cancellation of Permit, Date & Time:
Permit Receiver: …………………………………………………………...….. Permit Requestor: …………….................................……………………. _________________________________________________________________________________
Date & Time: …………………………………………………………...……….. Signature: ….......................................……………………………………………. _______________________________________________
⃝ Hold ⃝ Resume _________________________________________________________________
Reason for Hold-up, Date & Time: Work site checked / equipment taken over back after maintenance.
_________________________________________________________________________________________________________ Electrical Isolation / Tag has been removed.
__________________________________________________________________________________________ Permit Issuer (Process Owner): ………………………….....…………………………………..........
Date & Time: ……………………………………......... Signature: ……………………………….........
Job Resume Date & Time: ________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________________________________
_

White Copy: PTW Book (Permit Requestor), Yellow Copy: Permit Issuer / Process, Blue Copy: Permit Receiver
Safety Dept. Contact No.: 056 417 6699 / 02305 2521 First Aider No. 054 785 5786 / 02305 2536
White Copy: PTW Book (Permit Requestor), Yellow Copy: Permit Issuer / Process, Blue Copy: Permit Receiver
Safety Dept. Contact No.: 056 417 6699 / 02305 2521 First Aider No. 054 785 5786 / 02305 2536