PERMIT-TO-WORK

--------------------------------------------------------------------------------------------------------------------------------------------------------
THIS PERMIT TO WORK FORM IS REQUIRED FOR ANY RDPCI AND SUBCONTRACTOR ACTIVITIES

Instructions:
1. Verify the process of the activity. Check and completely fill up the information required.
2. Retain a copy for filing purposes.
3. A copy of the PTW must be displayed at the area where job or activity is to be done.
4. Upon completion of the activity or PTW expiration, PTW shall be return to the site safety officer or EHS designee.
5. If no Evaluation of Aspect/Hazard data is present, Aspects/Hazards checklist shall be completely fill up prior to the commencement
of activity.
Work Item/Activity: OPERATION/REPAINTING ASPHALT 09 Location/Area: MAMATITANG Contact #: 09984499216
Name of workers: Brief Description of Work / Activity (Include equipment, tool or materials to be
PLANT CREW used):
1. Operation and batch asphalt, loading aggregates using loader,
OFFICE STAFF_________________________
deliver mix using dump truck, Hot works and maintenance. Cleaning
GUARD ON DUTY_______________________ waste, Receiving and unloading delivery of aggregates, bitumen,
diesel. Heating asphalt. Implement social distancing. Awareness on
covid19, and wearing mask is a must. Renewal of self-declaration
form or it will depends on EHS guidelines.

PTW #: PLA-2007-001-SFT-PTW-1101

PART A. WORK REQUEST

PART B. TYPES OF ACTIVITY: PART C. TYPES OF CONTROL TO BE APPLIED:


PART D. BRIEF DETAIL IN EMERGENCY RESPONSE: BARRICADES  SIGNAGES

 Available service in case of emergency. HARD HAT  SPECTACLES
 Proper coordination of spotter and the operator of BH/pay loader; 
 Always check area, before proceeding to work SAFETY VEST RESPIRATORS
 Informing superiors in case of emergency 
 Report all possible unsafe condition tools/equipment/machine/and FACESHIELD EARPLUG/EARMUFFS
others before working; Avoid using of improvised hand tools 
 Availability of fire extinguisher within area FACEMASK ENGINEERING (Specify):
 GLOVES
PART E. OTHER SAFETY MEASURE/S RECOMMENDED (To be filled up by

Safety Officer): SAFETY SHOES

DECLARATION I understand will follow the precautions to be taken under this permit.
Name (Print): __Lemuel Dela Cruz______________________ Signed _______Lemuel Dela Cruz__ Date __11.02.2022_______

Permit validity period From: Date: __11_ / _02_ / __2022_ Time: _7_: _30_am To: Date _11_ / _30_ / _2022__ Time: _4_: _30_pm
Note: If the work is not completed within this timescale a new permit-to-work must be completed.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PART F: COMPLETION OF WORK
I confirm that the work has been completed in accordance with this permit. Area has been restored, safety signs have been removed and the
users/other workers were informed of the completion.

Signed _Lemuel Dela Cruz _____ Date __11.02.2022_

I confirm that I have inspected the work area detailed above and declare that to the best of my knowledge and belief the work was carried out
safely and without serious risk of injury to health.

Signed _________________ Date _______________

RDPCI-F-MPL-027
Rev. 2 12/14/16