General Work Permit (GWP)

Permit Number

Area Emergency Response No. / Radio Call Signs       (Facility Code -YYYY- GW - S/N)
Section A: General Information
Work Team Lead (WTL) Completes Section A or Provide Information & Permit Approver (PA) must Review and Accept
Facility Physical Location of Work Plant/Equipment Description
           
Requester:       Company:       JHA No.:      
(Facility Code- YYYY -PPHA-S/N)

Initial Duration – Date:      23/02/2020 Time:      06HRS To – Date: 23/02/2020      Time:      0600-1800

Description of work (Work LIMITED to following):

Tools/Equipment to be Used:

Previous content of Tank/Equipment (if applicable):      

JDE Work Order No. (If Applicable)      
Section B: Checklist for Site Preparation and Requirements
PA (Permit Approver) to Review Permit and Specify Requirements Check () If Completed
Site Checker (Operator/Facility Rep) must Verify all Requirements are Met Required (Name/Signature)
1. Isolation of Hazardous Energy? (Electrical, Mechanical, Equipment – LOTO)
2. Bypassing Critical Protections? (Bypasses must be Entered in the Facility Bypass Log/Register)
MOC No (If applicable)       MOC Approved Yes No

Date/Time Bypassed       Tag No.       Description       Reason for Bypass            

Date/Time Back in Service       Tag No.            

3. Provide Access? (e.g., Ladder, Scaffolding)

4. Barricade/Restrict Access? (X-ray, Road Closure, Confined Space Entry, Etc.)
5. Critical Lift? (Attach Rigging Diagram and Critical Lift Plan)
6. Night Work Special Lighting (Hazardous Location Rated)?
7. PPHA and/or JSA Reviewed and Confirmed Adequate? (Attach to Permit)
8. Other Special Requirements? (Specify)       NO USE OF MOBILE PHONE
9. Gas Testing Requirements (To be completed by a Qualified Gas Tester and Results Verified by Permit Approver
Not Required Initial Hourly Every _____Hrs Continuous Personal Gas Detector

Time LEL 0% O2 19.5 – 23% H2S  5 (ppm CO Others e.g. Instrument # Qualified Gas Tester (QGT) Name & Signature
ppm Benzene,
Mercury

                                         

     
Additional Gas tests to be captured on Gas Test log

Section C: Additional/Specialized Work Permits (Certificates)/Plans/Procedures (Mark in the box for required items)
Work Team Lead (WTL) Completes Section C or Provide Information, Permit Approver (PA) must Review and Accept
Hot Work Permit/Cert No:       Commercial Dive Operations Permit/Cert No:      
Confined Space Entry Permit/Cert No:       Lift Plan Plan No:      
Isolation of Hazardous Energy Permit/Cert No:       Key Safe:           Radiation Source Use
Energized Electrical Work Permit/Cert No:       Fire Water System Use
Road Block/Closure SIMOP’s Plan Required? Plan No:      
Excavation Permit/Cert No:       Description of SIMOP’s:      
     
List all Operations, Maintenance, Safety, Drilling & Completions etc. procedures required for this job
     

Section D: Special Equipment – Check All That Apply

Note: Hard Hats, Safety Glasses and Safety Footwear are Required in all Field Locations
Hearing Protection Work Gloves Ventilated Goggles
Chemical Protective Clothing Chemical Gloves Chemical Goggles
Eye Wash / Safety Shower Face Shield Fall Protection
SCBA / Supplied Air System Cartridge / Filter Respirator Ventilation Fan / Blower
Grounding / Bonding Radio Communication Personal Floatation Device (PFD)
Fire Resistant Clothing (FRC) Other (Specify): Other (Specify):
Section E: Approvals and Acceptance Name Signature Date Time

Site Checker: Section B Requirements Complete. this PTW are met) Work May Begin.                  

Work Team Lead (WTL): (I understand and agree to Permit conditions and have                  
communicated all conditions to Permit User(s). I verify that Requirements have been met).
Permit Approver (PA): (I agree the scope of work defined in Section A can be carried out .                  
provided all conditions specified on this PTW, associated Hazard Analysis and Specialized
Permits are met.) Work May Begin
Additional Approval(s) as required: I understand and agree to Permit conditions                        
Section F: Closure/Cancellation Name Signature Date Time

Site Checker: Certifies that Worksite has been returned to safe condition:                        
WTL (Work is Completed Cancelled Not Completed and site handed over in safe                        
condition)
Permit Approver: (Work Closed)                        
Additional Approvals (i.e. SME’s, Operations Superintendent, FM Manager, etc.)                        
If not complete, the work is in the following condition:
Section G: Permit Revalidation (Daily Renewal) PPHA No.:      
(Facility Code- YYYY -PPHA-S/N)

Permit must be comprehensively reviewed prior to revalidation. Allowed for only six (6) consecutive days use.

DD/MM/YY
From(Time): To (Time):

WTL:
PA (or degisnee e.g.
Site Checker):
Completed Permits Must Be Archived for a Minimum of One (1) Year

623965464.doc
Ebenco Global Links Permit to Work System
 General Work Permit (GWP)
Permit Number
(Facility Code -YYYY- GW - S/N)
Gas Test Log (incluing Revalidation Gas Tests)
 Initial Gas Test Recorded on Front of Permit
 Record Subsequent Test Results Here as Frequently as Indicated
 For Continuous Testing, Record Results Every 30 Minutes

Gas Detectors are Required to be Calibrated Monthly – Check Calibration Date to Ensure Current

Gas Detector – Type Calibration Bump

Serial Number Expiry Date
(Make / Model) Date Test
                        OK

                        OK

                        OK

                        OK

Gas Testing Requirements (To be completed by a Qualified Gas Tester and Results Verified by WTL and Site Checker
Not Required Initial Hourly Every _____Hrs Continuous Personal Gas Detector
Time LEL 0% O2 19.5 – H2S  5 (ppm CO Other e.g. Instrument # Qualified Gas Tester (QGT) Name & Signature
23.5% ppm Benzene,
Mercury
                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

                                               

*IMPORTANT: For Hot Work Conducted in a Confined Space – LEL Must Be 0%

Completed Gas Test Log Must Be Archived for a Minimum of One (1) Year

623965464.doc
Ebenco Global Links Permit to Work System
 General Work Permit (GWP)
Permit Number
(Facility Code -YYYY- GW - S/N)
Permit Revalidation Log
Permit must be comprehensively reviewed prior to allowing revalidation. Maximum of 12 hours time allowed for any one (1) work crew with possible 4hr extension. Not
allowed for continuous (24 hours day/night) projects. Allowed for only six (6) consecutive days use. Additional Revalidations to be documented on Revaliation log. Permit to
be revalidated if work conditions, WTL or Permit Approver changes, SWA is raised or there is an emergency. Refer to the PTW Procedure for additional revalidation
requirememts. New day and post incident/near miss revalidations to be approved by the Permit Approver..

DD/MM/YY
From: To:
WTL:
PA/Site Checker:
Reason for                                    
Revalidation

DD/MM/YY
From: To:
WTL:
PA/Site Checker:
Reason for                                    
Revalidation

DD/MM/YY
From: To:
WTL:
PA/Site Checker:
Reason for                                    
Revalidation

DD/MM/YY

From: To:
WTL:
PA/Site Checker:
Reason for                                    
Revalidation

DD/MM/YY

From: To:
WTL:
PA/Site Checker:
Reason for                                    
Revalidation

DD/MM/YY

From: To:
WTL:
PA/Site Checker:
Reason for                                    
Revalidation

DD/MM/YY

From: To:
WTL:
PA/Site Checker:
Reason for                                    
Revalidation

623965464.doc
Ebenco Global Links Permit to Work System