Permit to Work PTW No.

571745
No Work is so urgent that we cannot take time to do it safely
COLD WORK HOT WORK CONFINED SPACE ENTRY
SECTION 1 - REQUISITION(TO BE FILLED BY PERMIT APPLICANT) CONDITIONS TO BE IMPLEMENTEDBY RECEIVING AUTHORITY / WORK LEADER
Applicant Name: M Faisal Abu Bakar Dept/Company: Telecomm Technican Hazardous area classification Workers Accountability: Type Of Hot Work Control Required Entry Condition
Staff No:/IC No: 1057438 Location/Facility: RW TREATMENT (Please refer to HAC drawing) List of Name Welding Fire Extinguisher Respirable Atmosphere Whistle/ Horn
From: Date: 28-Feb-2022 Time: 07:00 SAP No.: Area: M227-UA1-4850 Zone 0 1) Flame Cutting Fire Retardant Screen Non-respirable Atmosphere Safety Line
To: Date: 07-Mar-2022 Time: 07:00 Zone 1 2) Grinding Fire Water Hose on Standby Inert Atmosphere Mobile Equipment Away from Manhole
Equipment No: Zone 2 3) Power brushing Spark Arrestor Control Required Rescue Plan Available
Description MCB601 : PRM Migration PAGA Access Console functional test (MCB601-PAC-023) for PTT Safe Zone 4) Blasting Cover Sewer or Drain or Sump First entry using BA? Or Airline? Entry Checklist Attached
Announcement, Auto and Manual Alarm test SIMOPS 5) Hot Tapping Fire Blanket Entrants CSE Certified? Entry Status Board Available
TAG No. Cabinet: CTR100-PAG-721/722/723/724/725/726 Assembly Area: MCB601 Gouging N2 or Steam Purge Entrants Briefed by Work Leader? Continuous Ventilation
SECTION 2 - HAZARDS HAZARDOUS ACTIVITIES Drilling Remove Ignition Sources Walkie Talkie Extra Low Voltage Lighting
Vehicle Entry Remove Flammable Material Verbal or Hand Signal Rescue Equipment at Site
Gas/ fume release Dust Falling object Hydrojetting Hand tools only Rotating equipment
Photo Taking Locate Spark Producing Equipment Away from
Volatile liquid under Pyrophoric material Radiation exposure Pressure test Electronic device Power brushing
Brazing
Chemical exposure Contact with hot Moving vehicle Drilling Generator/ Grinding
Electronic Devices Standby Person: Gas Monitoring
H2S release Adverse weather Moving crane Saw /cold cuts Lifting Interlock bypass
Heating Special Precautions: Name: Before work start
Steam release Electrical shock Flying object Battery operated / Radiography Blasting
Battery Operated Expiry date: Continous
Hot liquid/water Slip and fall Presence of N2 Welding Oxy-cutting Excavation
Pyrophoric materials Gas Monitoring Maximum entrants Every hours
Sharp object Slippery Floor Working at height Pneumatic tools Calibration
Before work start
Others: Others: Ensure vendor is trained and competent.
Others: Continous
SECTION 3 - WORKSITE PREPARATIONS/ PRECAUTIONS(TO BE FILLED BY AA & RA)
Every hours Special Precautions:
Equipment isolated Equipment inspected Opening covered to prevent fall Area baricaded/ warning sign available Fire Watch
Equipment/line blinded off Scaffold errected with valid green tag Brief JHA requirementto worker Name:
Equipment/line drained EIS implemented Materials/tools secured against falling Inform Area owner before work This permit is approved provided all conditions specified above are I have personally checked that all control measures are in place to prevent
Equipment/line depressurized Safety Critical Equipment (SCE) Setup water curtain Install extra light/warning light complied with release of hazards and complied with requirements of the certificate
N2 purged Instrumentation isolated
Steam purged Fire blanket installed
Flushed with water Earth leakage circuit breaker Others: Before and After trigger alarm need to do announcement and inform APPROVED BY APROVING AUTHORITY (AA) APPROVED BY APPROVING ENTRY SUPERVISOR(ES)
Valve locked/chained open/close Name: Name: Name:
SECTION 4 - PERSONAL PROTECTIVE EQUIPMENT (PRE) (TO BE FILLED BY AA & RA) Designation: Designation: Designation:
Signature: Date: Signature: Date: Signature:
Mandatory PPE RespiratoryProtection Eye, Face & Body Protection Fall Protection Personal Monitoring Device Hand Protection
Date:
Coverall (FRC) Full face mask Goggles Full body harness H2S meter Cotton gloves
Safety helmet Half face mask Face shield Safety net Distress unit Leather gloves GAS TEST MONITORING
Safety shoes SCBA Welding mask Guard/railing O2 monitor Rubber gloves
(CSE) Inert Initial Result (to be filled by
Safety glass Air line set Chemical suit Opening cover Dosimeter badge/film Chemical gloves Test (Non-CSE) Open Area (CSE) Respirable (CSE) Non-Respirable
Atmosphere AGT)
Hearing Protection Dust mask Disposable suit Fall arrest equipment Others: Cut resistance gloves Oxygen (%) 19.5 - 22.0 % 19.5 - 22.0 % < 19.5 % <5% %
Ear plug Hood Heat Retardant suit Life jacket / vest Flammable Gases < 10% LEL < 1% LEL < 10% LEL - %
Ear muff Organic vapor catridge Seat belt Toxic Gases (PEL) < PEL < 50% PEL 50% PEL but less than IDLH - %
H2S catridge Special precautions:
Mercury catridge To do announcement prior the PPM activities If any one of the condition are met, Oxygen level must be
All 3 conditions must be met All 3 conditions must be met
SECTION 5 - SUPPORTING CERTIFICATES/DOCUMENTS(TO BE FILLED BY RA/AA) Condition categorizedas non-respirable entry. maintain <5% to prevent
for hot work activity for entry.
HOT WORK is NOT PERMITTED combustion
Electrical Isolation certificateno : Road Closure certificateno :
Physical Isolation certificateno : Limit of Electrical Access AGT Name:
SCE Bypass certificateno : Vehicle Entry certificateno : Frequency of gas test Continous NA
Excavation certificateno : Mobile Crane Inspection required Every hours
Temporary Electrical Installation COVID-19 RTK Certificate: RTK Result test Signature: Date:
Radiation certificateno : Confined Space Pre-Entry Checklist : SECTION 7 - REVALIDATION (NOTE: EACH PERMIT SHALL BE VALID FOR 7 CONSECUTIVEDAYS ONLY. NEW PERMIT NEEDS TO BE ISSUED AFTER 7 DAYS)
Lifting certificateno : JHA Reference No : 558499 HANDBACK FOR INCOMPLETE WORK (Not applicable for CSE work) REVALIDATION (Not applicable for CSE work)
Lifting Plan : Procedure ref.No.(forJHA exception
AAR AA RA Work Leader
Rescue Plan : Others: Date RAR/RA Name Sign AA Name Sign
Day Night Day Night Day Night Day Night
SECTION 6 - JOINT SITE VISIT BEFORE WORK START / APPROVAL
I have personally checked the area and equipment to be worked on and I am satisfied the work requested can be carried out safely
RECEIVING AUTHORITY REPRESENTATIVE (RAR) APPROVING AUTHORITY REPRESENTATIVE (AAR)
Name: M Faisal Abu Bakar 1057438 Name: Eddy Tiong Mee Ting 1032396
Designation: Telecomm Technican Designation: Field Operator
Signature: SITE VISIT DONE BY RAR* Date: 28-Feb-2022 Time: 07:32 Signature: SITE VISIT DONE BY AAR* Date: 28-Feb-2022 Time: 08:13

APPROVED BY APPROVING AUTHORITY (AA) AGREED BY RECEIVING AUTHORITY (RA) AGREED BY WORK LEADER SECTION 8 - CLOSED
Work completed RECEIVING AUTHORITY (RA) ACCEPTED BY APPROVING AUTHORITY (AA)
I have checked and certify that the conditions and precautionsrequired I hereby accept the stated precautionsand onditions for the work to be done I have visited the site and understand the briefing of
Housekeeping completed Name: Name:
are as stated and I have discussed with RA accordingly safely and I have discussed with AA and will discuss with WL accordingly work condition and precautions. I accept the job and
Incomplete handback (please state reason) Designation: Designation:
Name: Khairi Anwar bin Ishak 1033028 Name: M Faisal Abu Bakar 1057438 Name: M Faisal Abu Bakar 1057438
Signature: Date: Signature: Date:
Designation: Shift Supervisor Designation: Telecomm Technican Designation: Telecomm Technican
Signature: APPROVE* Date: 28-Feb-2022 08:37 Signature: ACCEPT* Date: 28-Feb-2022 08:42 Signature: ACCEPT* Date: 28-Feb-2022 08:42
STOP WORK WHEN EMERGENCY ALARM IS ACTIVATED ** This is a system generated signature
Distribution - Original Copy : Display at work site Copy No.1 : Keep at PTW office Copy No. 2 : Keep by Receiving Authority
 Permit to Work PTW No. 571745
No Work is so urgent that we cannot take time to do it safely
COLD WORK HOT WORK CONFINED SPACE ENTRY
GAS TEST MONITORING

Time Tested LEL (%) O2 (%) H2S (ppm) CO (ppm) Benzene Other AGT Name AGT Initial
 Permit to Work PTW No. 571745
No Work is so urgent that we cannot take time to do it safely
COLD WORK HOT WORK CONFINED SPACE ENTRY