8/2/22, 9:57 AM Gmail - PDB Work Clearance Form

Petronation hse <petronation.hse@gmail.com>

PDB Work Clearance Form

Google Forms <forms-receipts-noreply@google.com> 29 July 2022 at 10:49

To: petronation.hse@gmail.com

Thanks for filling out PDB Work Clearance Form

Here's what was received.

PDB Work Clearance Form

No Work Is So Urgent That We Cannot Take Time To Do It Safely

Email *

petronation.hse@gmail.com

 Date *

MM DD YYYY

07 / 29 / 2022

Contractor Name, as per IC (Work Leader): *

Example : Dollah Saleh bin Othman

Azwan Sinsian

Company Name (Work Leader): *

PETRONATION SDN BHD

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Other workers' names

Nama - nama pekerja yang lain

Gamil,yusup

PTW Authorization Number (Work Leader): *

PDB/RBD/21125399

PETRONAS Station Location: *

Penampang 1

Region *

Northern

Eastern

Central

Southern

Sabah

Sarawak

Equipment ID/No.:

Mesralink Report no.: (fill in the correct number; Example: 00636280) *

If No, Write NA (Not Applicable)

01238738

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Work Without Mesralink No.

(Project Number / Service Number / Project Code etc)

Detailed description of work, along with tools and equipment to be used: *

Penerangan terperinci mengenai kerja,  alat dan peralatan yang akan digunakan:

Roof leaking seriously at Tealive during heavy rain,silicon and hands tool only

Type Of Work

Equipment / Non - Equipment / Visual Element / Server Related Work

Choose Only One *

Non-equipment

Non - Equipment

Work carried out at :

1. Building, Kedai Mesra, Surau, Toilet or

2. Forecourt Area, Compound Area, Driveway, STP manhole

Choose Only One *

Building, Kedai Mesra, Surau, Toilet

Building, Kedai Mesra, Surau or Toilet

Working At Height Using Ladder / Electrical Works & Physical Isolation / Physical Isolation Work ONLY /
Electrical Work ONLY / Hacking or excavation / Building Work Without Working At Height / Working At Height

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Using Mobile Elevated Working Platform

Choose Only One *

Working At Height Using Ladder

Working At Height Using Ladder

Kerja di tempat tinggi menggunakan tangga

Worker is wearing the following PPE *

Pekerja memakai Pakaian Perlindungan Kendiri (PPE) seperti yang berikut

Cotton Glove, Reflective Vest, Safety helmet, Non Slip safety Shoes & Dust mask (if work results
✓
in release of dust)

Work area is barricaded *

Kawasan kerja diletak hadangan

✓ Yes

The work shall be carried out by a minimum of 2 person (buddy system). A person
is assigned to hold the ladder steady while the worker is on the ladder. *
Kerja ini mesti dilakukan oleh minimum 2 orang . Satu orang perlu ditugaskan untuk memegang tangga
dengan stabil semasa pekerja berada di tangga.

✓ Yes

Permit Approval

I have personally checked the area and equipment to be worked on and am satisfied that site preparation
and safety precautions as specified in this PTW have been completed or in place for the work to be carried
out safely.

Saya secara peribadi telah memeriksa kawasan dan peralatan yang akan digunakan dan berpuas hati
bahawa penyediaan tempat dan langkah keselamatan seperti yang dinyatakan dalam PTW ini telah
dilakukan atau berada ditempat kerja dan ianya dapat dijalankan dengan selamat.

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If other controls are deemed necessary, please specify:

Sila nyatakan, sekiranya langkah kawalan lain perlu dilakukan.

Rakan Niaga (Dealer) / Station Supervisor *

Example : Marina binti Rahman

Rizuan

Contractor Name (Work Leader) *

Example : Dollah Saleh bin Othman

Azwan sinsian

Submission Of Work Clearance Form To Rakan Niaga (Dealer) / Station Supervisor

by Contractor *

✓ YES

[Quoted text hidden]

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