MANUAL HSE

Anexo 2
Seguridad, Salud Ocupacional Procedimiento HSE 2.21
y Medio Ambiente Revisión B, Agosto 2012
Pagina 1 de 1

Formulario para Autorización de Permiso de LOTOTO

LOTO Clearance Attachment 2

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

Confined Space Permit? Y  N  Hot Work Permit? Y  N 
Clearance Number (if yes, enter permit number below) (if yes, enter permit number below)

LOTO Requested By Work to be performed

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

Note: If additional work or Authorized Employees, attach an Additional Employee Clearance Sheet (see Attachment—C).

Device or Equipment Isolated Position Application Removal

Tag Lock #
(list affected equipment) (Open/Closed/Off/On/Etc.) Date / Time / Initial Date / Time / Initial

Additional Equipment Isolated? Y  N  (if yes, complete and attach an Additional Equipment Isolation Sheet, see Attachment D)

LOTO Verified By Zero Energy Tested

(System Authorized Employee print and sign name) Date / Time (Authorized Employee print and sign name) Date / Time

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

L#

H W

L#
Authorized Employee(s)

H W
L#

H W

L#

H W

Additional Authorized Employees? Y  N  (if yes, complete and attach an Additional Employee Clearance Sheet, see Attachment C)

LOTO Approved By LOTO Released By

(Primary Authorized Employee print and sign (Primary Authorized Employee print and sign name)
Primary

Date / Time Date / Time

name)

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