954 Doc.

RC/EG/09

WORK PERMIT TYPE (PLEASE TICK)

HOT J HEIGHT cONFINED cOLD ELECT.

ROOF PIPE LINE FIRE SAFETY OTHER

Maintenance
Date Valid:
Oo 122 Plant Area: Osc oddu -

Start time: Pormit Holder:KodheyLasona Projoct

10 3 o mn
Process
Finish time :
o:3 o Pm . Company hnldeeh erk
..By (Slgnature ) . . Date
Pemit Extensions: Extended until time. ********** ***

Pemit Issued By u a n ... (Signature). ... *s*sasa nass*********.o Date.061224

1.Descrption andlocationofwork: uteduaio Rau fem u F 0SC Codou
Specify equipment name / numbers
Equipment &Tools to be used for the work Zone
Risk Category Ves)
2. Specific hazards LIkely hood Severity
Hi (H/ML (S/ML)
3. Gas Test: % LEL.e*o**.*.. o 02.. . PPM CO... ************* Time ************************ Tested By . . . .

Dust levels in area satisfactory Yes No N/A L Time.. Visually Checked By.

4. Is continuous Monitoring required for the duration of entry ? Yes No

5. Continuous communication has been established priorto entry of entry 7 Yes
Time Bestored by Time Location of
6. Nature of Isolation Required lsolated Inspected
(Yes/No) by by Isolation
Depressurized / drained
Equipment ventilated

Equipment flushed

Electrical motorlockout
Electrical panel isolation
Compressed air isolation

Others (Specify)
7. Additional conditions / comments . .. NA..........J. ... . *** .. ************"

* * * * * "**************** ****

Hot Work:Wark area clear of Combustible materials by 1 M7 Yes No Fire Extinguisher in place Yeso
Height Suitable weather condition Yes NoExact location of secure points
Control Measures to be in place / used (Y/N)
Sec
Approved face / Eye protection Standby Man

Head Protection Diversion in Place

Respiratory Protection Type ? Fire Extinguisher (s) Sately Officer's Signature

Fall Protection Type ? Water House

Foot Protection Sand buckets

Hand Protection Type? Good Housekeeping

Ear Protection Other Security In Charge Signature

8. Iamsatisfedthattheareaisinasafe conditionfor thework to be camied out, provided thaj . e fonditions listed this permit
Pemlt Authorizer
on are adhered to at al
times. I have checked other work in the area to ensure no confics are possitle
(Process owner)
9. 1am aware ofthe hazards related to this work, and have placed my locks on the isolation points provided as required. I shallensure that the
conditions imposed upon me by this pemit are adhered to throughout the course of the work - A P e r s o n s perfoming the work

10. The work is (Complete]/ [ Incompletel and the area has been left in a clean condition and all debris removed
. . . P e m t Holder

11. Ihave verified that the area has been left in a safe &clean condition and that for hot works, thereis&Cconstant fre watch 3 hour ater
completion of Hot Work ********
P e r s o n s perfoming the work

12. PERMIT CLOSED(BY ISSURE)

Signature Name- A -Date 0,l 2_Tme