Date

Applied:
LOTO CLEARANCE LOTO No.
PTW Ref
IMPORTANT: This Clearance shall be accompanied with the Energy Isolation List Form
No.
Sec. 1.0: DEFINITION

The objective of isolation is to control all hazardous energy sources from the plant or equipment thereby achieving safety for persons while servicing or doing maintenance.

Isolation is the physical removal of energy sources and substances, which are potentially hazardous to any person performing work on the equipment. It involves the physical
disconnection of electrical supply; closure of valves; draining, flushing; venting, purging of lines, blinding, and placement of locks and tags. On the completion of isolation, a
Zero Energy Test shall be carried out to confirm if all sources of energy have been removed from the equipment to be worked on.

Sec. 2.0: WORK INFORMATION (Permit Issuer)

Equipment and
Work Scope:

Area/ Location: Other Info:

Sanction to Test
P&ID Others
Form
Ref. No. or N/A Ref. No. or N/A Ref. No. or N/A

Sec. 3.0: ISOLATION AND LOTO (Isolation Officer, Permit Issuer, Permit Receiver, and Work Party)

Authorization to Isolate

Permit Issuer Signature Date and Time Lock Out Box No.

Zero Energy Test

Zero Energy Test Performed by: Signature Date and Time Zero Energy Test Verified by: Signature Date and Time

LOTO Issuance Permit Receiver acknowledges all the points of isolations made

Permit Issuer Lock No. Signature Date and Time Permit Receiver Lock No. Signature Date and Time

WORK PARTY SIGN-ON AND SIGN-OFF LOTO

Personal SIGN ON LOTO SIGN OFF LOTO
NAME Contact No.
Lock No. Date and Time Signature Date and Time Signature

Sec. 5.0: DEISOLATION AND REINSTATEMENT (Permit Receiver, Isolation Officer, and Permit Issuer)

The equipment is fully assembled and operational, all tools and non-essential
items are removed
Permit Receiver Signature Date and Time

The workplace is cleared of material, tools, personnel, equipment, and

scaffoldings.
Permit Issuer Signature Date and Time

All Lock/s and Tag/s has been removed and returned to the PTW Room
Isolation Officer Signature Date and Time

Permit Issuer (original) copy - available at the PTW room. Permit Receiver copy - available at the job site.
COA-SHE-001-F047
Rev.00 / 2021.01.30