PERMIT TO WORK

PTW No: 0072429

NO WORK IS SO URGENT THAT WE CANNOT TAKE TIME TO DO IT SAFELY

SECTION 1 - REQUISITION Cold Work Hot Work HOT WORK CERTIFICATE CONFINED SPACE ENTRY CERTIFICATE
AREA CLASSIFICATIONS CONDITIONS TO BE IMPLEMENTED BY RECEIVING AUTHORITY / WORK LEADER
APPLICANT'S NAME: Ramli Palilang Department/Company: PETRONATION Safe TYPE OF HOT WORK PRECAUTIONS: ENTRY TYPE GAS MONITORING
Staff no./IC no.: AT961344 Location/Facility SABAH Gas Monitoring
Zone 0 Welding Irrespirable Atmosphere Continous
Equipment no.: Area: SABAH
Zone 1 Flame cutting Continous Respirable Atmosphere Interval Hrs
WORK DESCRIPTION: Membaiki lampu fascia
Zone 2 Open flame Interval Hrs TYPE OF COMMUNICATION Initial Gas Test only
SECTION 2 - HAZARDS/HAZARDOUS ACTIVITIES Grinding Initial Gas Test only Entry status board / log CSE Items
Blasting FIRE WATCHER Rope Signal Complete CSE checklist
Slippery floor Sharp objects/edges Hot surfaces
Power brushing S.No Name Card No. Signature Rubber gloves Confined space entry checklist attached
Moving vehicle/ machinery Rotating parts Dropped objects
Gouging Walkie Talkie Continuous ventilation
Fall from height Electrical Gas / fumes Fire extinguisher
Post weld heat treatment Whistle/horn Entrants are CSE certified
Chemical Ionizing/radiation Electromagnetic field Fire blanket
Use of pyrophoric material Fire retardant screen Max. person at entry persons Entrants briefed of risk by Work Leader
Extreme weather Hydrocarbon Flying debris
Photo taking Entrants physical & medical conditions certified
Wild animals / insects Oxygen deficiency Poisonous substance Fire hose on standby
fit by OHD
Infectious substance Pinch point Noise Hot tapping Cover potentially flammable sewer/drain/sump Extra low voltage lighting (50V maximum)
Congested site due to vehicles Vehicle entry Locate spark producing equipment away from First entry using SCBA or air line set
Special Precaution: Others: potentially flammable sewer/trench
Locate mobile equipment away from manhole
Spark arrestor
SECTION 3 - WORK SITE PREPARATION/PRECAUTIONS Rescue & evacuation plan attached
Remove flammable/highly combustible material
Flammable / combustible materials removed Area barricaded Rescue equipment at site
Special Precautions:
Warning signs in place Scaffold erected and safe to be used This permit is approved provided the above conditions and precautions are Special Precautions:
Secure tools/materials against falling Earth Leakage Circuit Breaker (ELCB) implemented I have personally checked that all control measures to prevent release of hazard
have been put in place
Contact area owner before work start Proper access / egress to work area
Name: Name:
Heavy machinery/vehicle has roll-overprotection Openings with potential to fall through are covered (floor & wall) Department: Designation: Department: Designation:
Portable electrical temporary installation has been inspected & tagged Equipment Isolation ………………………………… ………………………………… ………………………………… …………………………………
Equipment/line blinded off Signature: Date: Signature: Date:
Others: GAS TEST RESULTS
SECTION 4 - PERSONAL PROTECTIVE EQUIPMENT Test Confined Space Standard
Mandatory Respiratory Protection Eye, Face & Body Hearing Protection Oxygen 20% - 20.9% 20% - 20.9% AGT Name: Date:
Helmet Half mask respirator Protection Ear plug Flammable Gases < 1% LEL < 10% LEL Status: Time:
Safety shoes Full face respirator Goggles Ear muff Toxic Gases < 50% PEL < PEL
Safety glass SCBA Face shield Hand Protection
Welding mask Cotton gloves SECTION 7 - REVALIDATION
Approved coverall Air line set
Reflective Vest Dust mask Disposable suit Leather gloves Date
Hood Chemical suit Rubber gloves 04/07/2022
Rubber boots Chemical gloves 05/07/2022
Personal Monitoring Equipment Fall Protection 06/07/2022
Personal distress unit Full body harness with double lanyards 07/07/2022
Personal O2 monitor Full body harness with single lanyards 08/07/2022
Personal dosimeter/ Film badge/ Survey meter Fall Arrest Equipment 09/07/2022
Others: 10/07/2022
SECTION 5 - SUPPORTING CERTIFICATES/DOCUMENT
SECTION 8 - PTW HAND BACK
Job Hazard Analysis Job method statement or procedure Portable Equipment & Temporary Installation Certificate (PETI) Excavation Certificate Physical Isolation Certificate
Work Completed
Lifting Certificate Safety Data Sheet Confined Space Entry Certificate Diving Certificate Electrical Isolation Certificate Incomplete Handback
Limit of Electrical Access Certificate Lifting Plan Rescue Plan Road Obstruction Certificate Safety System Bypass Certificate Housekeeping Completed
Vehicle Entry Certificate Others-Drawing Others-Permit Mesin Tekanan (PMT) Others Name: Azrol Mohamad Asli Name: Donny Kerk Ho Ann
SECTION 6 – JOINT SITE VISIT BEFORE WORK START / APPROVAL (In the event the RAR and/or AAR are not attended, the RA and AA shall act as the RAR and AAR) Signature:----------- Signature:-----------
Date/Time: 05/07/2022 10:44:39 AM Date/Time: 05/07/2022 11:11:34 AM
RECEIVING AUTHORITY REPRESENTATIVE
I have personally checked the area and equipment to be worked on and am satisfied the work requested APPROVING AUTHORITY REPRESENTATIVE
can be carried out safely. I have personally checked the area and equipment to be worked on and satisfied the work requested
Name: can be carried out safely.
Designation --------- Name: Donny Kerk Ho Ann
Status: Designation ---------
Date: Signature:: Approved
Signature:: -------- Authorised No: --------
Authorised No: --------
AGREED BY WORK LEADER AGREED BY RECEIVING AUTHORITY APPROVED BY APPROVING AUTHORITY
Name: Ramli Palilang Name: Ramli Palilang Name: Donny Kerk Ho Ann
Signature ----------- Signature Agreed Signature -----------
Date: Time: Date: 04/07/2022 Time: 11:47 AM Date: 04/07/2022 Time: 11:48 AM
Authorisation No -------------- Authorisation No -------------- Authorisation No --------------
Tick where relevant STOP WORK AND EVACUATE AREA ON HEARING OF EMERGENCY ALARM HPTW 100115 R2
* Delete if not applicable Distribution: Printed copy - Receiving Authority (Work Leader) to display at Worksite
GAS TEST RESULTS
Date Time O (20-21%) LEL ( < 10%) Toxic ( < PEL) AGT Name AGT Signature

WORK LEADER/ SUPERVISOR

No. Name Designation / Position Department / Company Date Time Signature
1 Mazlan Station Supervisor PS JALAN BOKARA 04 Jul 2022 11:47 AM
2 Masir Bin Israk Work leader PETRONATION SB 04 Jul 2022 11:46 AM