Doc Number: BK9A-GEN-000-HSE-PTW-0003 Rev: A

SPARK POTENTIAL WORK PERMIT

S PERMIT No. VALID FOR A MAXIMUM OF 7 CONSECUTIVE DAYS FROM DATE OF FIRST ISSUE
SPECIFICATION OF WORK (To be completed by Permit Originator)

GENERAL TASK INFORMATION Work Order No:
Permit Originator Name:
Permit Originator Sign:
Associated Permits:
Worksite/Location: Work in Confined Space Pigging Breaking of Containment
Designation: Isolation of Safety Systems Pressure Testing Excavation Work
Contact No: Hazardous
Critical Lifting Substances /COSHH Work on Critical Systems
Equipment System to be Worked on:
Blinding/De-blinding Work on Control System Working at Height
Draining/Purging of Flammable/H2S to Atmosphere/Open drain
Unit / Tag No: Work on pressurized system

Other ____________________________________

Date Work to Start: Time to Hrs.: Date of Expected Completion of Work: Time to Hrs.:
Work Description:

Tools Involved: Hand Electrical Pneumatic Hydraulic Others (Specify)

RISK ASSESSMENT
RISK ASSESSMENT

HAZARDS BY PERMIT ORIGINATOR: ( Verified by the Performing Authority)

CONTROL MEASURES BY PERMIT ORGINATOR: ( Verified by the Performing Authority)

SUPPORTING DOCUMENTS / CERTIFICATES REQUIRED (By Performing Authority):

SUPPORTING DOCUMENTS

RA METHOD STATEMENT LIFTING PLAN OTHER (Specify)

ASSOCIATED CERTIFICATES
Document Type Certificate No: Document Type Certificate No: Document Type Certificate No:
Preparation / Reinstatement Mechanical / Electrical Isolatio Radioactive material

Excavation Confined Space Entry Other

COSHH Scaffolding Other

EMERGENCY CONTACT DETAILS

Name: Contact details KEC Emergency Number 0771 918 1857

PERFORMING AUTHORITY AGREED FOR WORK TO PROCEED
I) The work and precautions will be carried out under my overall responsibility. 2)All personnel under my supervision have been fully briefed and understand the Permit to Work / Site Safety Rules.

Name: _____________________________________ Signature: _________________________ Company Name:____________________________________ Date: ____________________ Time:

________________________
ISSUING AUTHORITY: I certify that I am aware of the planned work and the controls detailed on the work permit and all the conditions set out in the document are met
ACCEPTANCE

Name: ________________________________________ Designation: _____________________ Signature: __________________________ Date: ________________________ Time:

_____________________________

AREA AUTHORITY DECLARATION: I/my appointed delegate have/has inspected and confirm the worksite has been prepared according to the above
I) The work and precautions will be carried out under my overall responsibility. 2)All personnel under my supervision have been fully briefed and understand the Permit to Work / Site Safety Rules.

Name: _____________________________________ Signature: _________________________ Date: ________________________________ Time: ________________________

GAS TEST (Authorized Gas Tester): PERMIT REVALIDATION BY PERFORMING AUTHORITY

Date I have confirmed the task hazards and risks have been assessed and any additional hazards have been
Time listed and controls have been put in place.

O2 Date
LEL Time
H2S Name

Signature
Signature
AA Sign
PTW EXTENDED BY: AREA AUTHORITY APPROVAL OF EXTENSION / HANDOVER
I/My appointed delegate has confirmed checks have been made that plant remains safe to work upon, and
Date Time
new performing authority and permit to work users are fully aware of hazards and precautions.
EXTENSION

Name Signature Name Signature

Designation Designation Date Time

Date Work to Start: Date of Expected Completion of Work: Time from Hrs.: Time to Hrs.:

HANDBACK OF EQUIPMENT BY PERFORMING AUTHORTY CANCELLATION OF PERMIT BY AREA AUTHORITY

In Liaison with Area Authority, I/my appointed delegate have inspected the Worksite: I/My appointed delegate have inspected the area/equipment and agree/disagree it is in the
condition stated:
CANCELLATION / HANDBACK

Is completed and area cleaned Is to continue on another Permit. All isolations have been removed.. Isolations are still in place.

Requires Long Term Isolation Can be returned to service. Cannot be returned to service.

Performing Authority. ______________________________________ Date:_____________ Time:

____________
The completed permit(s) / associated permit(s) / certificates are now closed.
Signature:______________________________________

Area Authority. _________________________________________Signature_____________________________________Date: ______________ Time: ______________

Issuing Authority. ________________________________________Signature_____________________________________Date: ______________ Time: ______________

Original : Performing Authority: Copy1: Permit to Work Station: Copy 2: CoW Office: