Suriname Alcoholic Beverages N.V. en SAB Distribution N.V.

PERMIT TO WORK

Location Permit No.

Date Start Time Expiry Time
No. of Workmen
Job Description

General Type Work Yes No N/Req. Safety Equipment Required

1. Equipment out of service    S. Glasses 
2. Electricity supply locked off    Goggles 
Eyes
3. Gas Supply isolated    Face Shield 
4. Isolating valves and Ear Plugs/Muffs 
switched locked and    Hard Hat 
tagged Extr. Gloves 
7. Pressure released in Line    Boots 
8. Line/Unit sufficiently cooled    Coveralls 
Body
9. Warning signs or cones in Normex Suit 
  
place Airline 
11. Fire equipment accessible APR 
   Respirator
in area SAR 
SCBA 
Hot Work Yes No N/Req. Safety Belt 
1. Equipment out of service    Lifeline 
2. Electricity supply locked off    Rescure Harness 
3. Gas Supply isolated    Wristlets 
4. Isolating valves and Life Ring 
  
switched locked and tagged
6. Is the work area free of
flammable materials and Time O2 % H2S % CO % LEL%
  
provisions made to contain
sparks of fire
10. Line/Unit sufficiently cooled   
11. Warning signs or cones in
  
place
13. Fire equipment   
14. Is blinding necessary and
  
done
16. Will non spark tools be
  
used
17. Is Equipment/Lines De-
Pressurised, drained,    Alarm Set points
purged flushed and isolated High Alarm Low Alarm
O2 22% 19.5%
H2S 10 ppm ——
CO 35 ppm ——
LEL 10% ——

Doc naam: HSEQ-FR-005-Permit To Work Revisie: 01

Eigenaar : HSEQ Manager Datum : 4 juni 2018 Pagina 1 van 2
Suriname Alcoholic Beverages N.V. en SAB Distribution N.V.

PERMIT TO WORK (continuation)

Location Permit No.

Date Start Time Expiry Time

Confined space Yes No N/Req.

1. Is the confined space completely isolated by blinding or spool
removal   

4. Is the confined space completely isolated from all hazardous

  
energy
5. Is the confined space empty and free of all sludge and debris   
6. Does the confined space have adequate ventilation   
7. Is an auxiliary blower necessary   
8. Is the confined space free from all toxic and flammable
  
materials
9. Is access/egress to confined space adequate   
10. Is the confined space properly illuminated   
11. Are explosion proof and no spark tools to be used   
12. Is the attendant (Buddy) aware of emergency plans, and the
  
need for constant communication with entrant
13. Are the fire fighting and First Aid kit readily available   
14. Is the Confined space’s work area sufficiently cooled (ambient
  
temperature)
15. Have gas levels been measured in the confined space   

Other
Precautions

I certify that I have checked the job site and I am satisfied that it is safe to perform work in the area, as
all the necessary safety precautions above have been established.

Suriname Alcoholic Beverages N.V.

Name employee
Name HSEQ dept.
performing the task
Signature Signature
Date Date

Doc naam: HSEQ-FR-005-Permit To Work Revisie: 01

Eigenaar : HSEQ Manager Datum : 4 juni 2018 Pagina 2 van 2