Certificate

C4 Pre-start Safety Review Certificate

ISC-CERT-A-004 (U15)

Phase: C4 Wet Commissioning & Pre-Start Safety Review (PSSR)

Project: Industrial Business Solutions Project No. Alpha Database

Certificate Description: Certificate C4 Pre-start Safety Review (PSSR)

-
Area: Location/Facility:

DRAINS, UF/RO REJECT SUMP &

System Ref. 1100-112-04 System Description:
PUMP

Sub-system Ref. 1100-112-04-02 Sub-system Description: Sump and Pumps

Applicability
Item Document Number Comment
Yes No N/A

HEALTH, SAFETY, SECURITY AND ENVIRONMENT REQUIREMENTS:

A Pre-Commissioning Readiness & Risk

Review, including a risk assessment
(HAZID) has been completed using the
Origin Risk Matrix and all critical controls
have been implemented.
Notification of Energisation /
Commissioning issued to affected site
personnel.
Communications, sirens and paging
systems are tested and operational

SITE READINESS:

P&IDs and other critical start-up

documentation have been As-Built.
Note: Red-line mark-ups acceptable,
Safety-related painting, signage and PPE
notices installed
Restricted and Hazardous area signs in
place for relevant restricted areas (where
required)
Safeguards including chains, cross walks,
railings, curbs, guardrails, and platforms
are installed
All mechanical tools/equipment and
combustible materials not required for
commissioning have been removed
Eye wash stations and safety showers
installed and tested

Tag No: Planned Task ID: T-00001-0015

Doc Ref: ISC-CERT-A-004 (U15) Revision: A Example Company Page 1 of 3
 Certificate
C4 Pre-start Safety Review Certificate
ISC-CERT-A-004 (U15)

Applicability
Item Document Number Comment
Yes No N/A
All utilities and ancillaries have been
service-tested and are operational
Emergency power and communications
systems are tested and functional, backup
batteries are fully charged if available
Scaffolding and temporary platforms
installed (where required)
All machine guards are installed and
provide suitable protection from exposure
to moving components

COMMISSIONING READINESS:

Verify Ready for Commissioning

Certificate (C3) has been signed off.
All commissioning plans, startup,
shutdown and emergency procedures have
been reviewed and are approved and
available for use.
No wet commissioning circuit conflicts
identified.
Final check and leak tests on flanges
performed.
Testing and labelling of start and stop
buttons and isolators complete.
All equipment is labelled, locked, car-
sealed and commissioning tags hung as
required.

Pre Start-Up Approval

THIS CERTIFICATE IS ISSUED IN RESPECT OF COMPLETION CERTIFICATES C1, C2 AND C3 CERTIFYING THAT THE SYSTEM/SUB-SYSTEM
REFERENCED IS PRACTICALLY COMPLETE, AND HAS HAD ALL NECESSARY TESTS CARRIED OUT IN READINESS FOR SAFE
COMMENCEMENT OF OPERATION. ALL ITEMS ON THIS CERTIFICATE ARE COMPLETE AND HAVE BEEN DULY CLOSED OUT,
ALLOWING COMMISSIONING OF THE SYSTEM/SUBSYSTEM TO PROCEED.
I HEREBY ACCEPT THE HANDOVER PACKAGE(S) AND SUBJECT TO THE RESPONSIBILITIES/LIMITATIONS BEING COMPLETED AS
DEFINED ON THE PUNCHLIST(S) AND COMMISSIONING RISK REGISTER, AGREE THAT THE SYSTEM/SUB-SYSTEM
REFERENCED IS READY FOR NITROGEN PURGE, INTRODUCTION OF HYDROCARBONS, HAZARDOUS FLUIDS AND/OR
PROCESS COMMISSIONING.

COMMISSIONING REPRESENTATIVE

Signature: A SAI NADHA REDDY Date:

Name: Position:

OPERATIONS SUPERINTENDENT
Tag No: Planned Task ID: T-00001-0015
Doc Ref: ISC-CERT-A-004 (U15) Revision: A Example Company Page 2 of 3
 Certificate
C4 Pre-start Safety Review Certificate
ISC-CERT-A-004 (U15)

Signature: Date:

Name: Position:

Comments

Tag No: Planned Task ID: T-00001-0015

Doc Ref: ISC-CERT-A-004 (U15) Revision: A Example Company Page 3 of 3
 Certificate
C4 Pre-start Safety Review Certificate
ISC-CERT-A-004 (U15)

Phase: C4 Wet Commissioning & Pre-Start Safety Review (PSSR)

Project: Industrial Business Solutions Project No. Alpha Database

Certificate Description: Certificate C4 Pre-start Safety Review (PSSR)

-
Area: Location/Facility:

DRAINS, UF/RO REJECT SUMP &

System Ref. 1100-112-04 System Description:
PUMP

Sub-system Ref. 1100-112-04-01 Sub-system Description: Piping and Drainage

Applicability
Item Document Number Comment
Yes No N/A

HEALTH, SAFETY, SECURITY AND ENVIRONMENT REQUIREMENTS:

A Pre-Commissioning Readiness & Risk

Review, including a risk assessment
(HAZID) has been completed using the
Origin Risk Matrix and all critical controls
have been implemented.
Notification of Energisation /
Commissioning issued to affected site
personnel.
Communications, sirens and paging
systems are tested and operational

SITE READINESS:

P&IDs and other critical start-up

documentation have been As-Built.
Note: Red-line mark-ups acceptable,
Safety-related painting, signage and PPE
notices installed
Restricted and Hazardous area signs in
place for relevant restricted areas (where
required)
Safeguards including chains, cross walks,
railings, curbs, guardrails, and platforms
are installed
All mechanical tools/equipment and
combustible materials not required for
commissioning have been removed
Eye wash stations and safety showers
installed and tested

Tag No: 0000--0390 Planned Task ID: T-00001-0014

Doc Ref: ISC-CERT-A-004 (U15) Revision: A Example Company Page 1 of 3
 Certificate
C4 Pre-start Safety Review Certificate
ISC-CERT-A-004 (U15)

Applicability
Item Document Number Comment
Yes No N/A
All utilities and ancillaries have been
service-tested and are operational
Emergency power and communications
systems are tested and functional, backup
batteries are fully charged if available
Scaffolding and temporary platforms
installed (where required)
All machine guards are installed and
provide suitable protection from exposure
to moving components

COMMISSIONING READINESS:

Verify Ready for Commissioning

Certificate (C3) has been signed off.
All commissioning plans, startup,
shutdown and emergency procedures have
been reviewed and are approved and
available for use.
No wet commissioning circuit conflicts
identified.
Final check and leak tests on flanges
performed.
Testing and labelling of start and stop
buttons and isolators complete.
All equipment is labelled, locked, car-
sealed and commissioning tags hung as
required.

Pre Start-Up Approval

THIS CERTIFICATE IS ISSUED IN RESPECT OF COMPLETION CERTIFICATES C1, C2 AND C3 CERTIFYING THAT THE SYSTEM/SUB-SYSTEM
REFERENCED IS PRACTICALLY COMPLETE, AND HAS HAD ALL NECESSARY TESTS CARRIED OUT IN READINESS FOR SAFE
COMMENCEMENT OF OPERATION. ALL ITEMS ON THIS CERTIFICATE ARE COMPLETE AND HAVE BEEN DULY CLOSED OUT,
ALLOWING COMMISSIONING OF THE SYSTEM/SUBSYSTEM TO PROCEED.
I HEREBY ACCEPT THE HANDOVER PACKAGE(S) AND SUBJECT TO THE RESPONSIBILITIES/LIMITATIONS BEING COMPLETED AS
DEFINED ON THE PUNCHLIST(S) AND COMMISSIONING RISK REGISTER, AGREE THAT THE SYSTEM/SUB-SYSTEM
REFERENCED IS READY FOR NITROGEN PURGE, INTRODUCTION OF HYDROCARBONS, HAZARDOUS FLUIDS AND/OR
PROCESS COMMISSIONING.

COMMISSIONING REPRESENTATIVE

Signature: Date:

Name: Position:

OPERATIONS SUPERINTENDENT
Tag No: 0000--0390 Planned Task ID: T-00001-0014
Doc Ref: ISC-CERT-A-004 (U15) Revision: A Example Company Page 2 of 3
 Certificate
C4 Pre-start Safety Review Certificate
ISC-CERT-A-004 (U15)

Signature: Date:

Name: Position:

Comments

Tag No: 0000--0390 Planned Task ID: T-00001-0014

Doc Ref: ISC-CERT-A-004 (U15) Revision: A Example Company Page 3 of 3