PERMIT-TO-WORK

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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: STANDBY FOR CRUSHING PLANT Location/Area: Pangasinan Umingan Contact #: 09985914501
Name of workers: Brief Description of Work / Activity (Include equipment, tool or materials to be
PLANT CREW AND PLANT MAINTENANCE used):
BH OPERATOR, PL OPERATOR, CRANE OPERATOR, (if there 1. Crusher Operational. Loading river mix into jaw crusher, update

is any requested) checklist daily preventive. Apply 5’s within working area.
OFFICE STAFF_________________________ Continue assembly for motor pool. Work at heights hot works
GUARD ON DUTY_______________________ using welding machine and cutting set. Assembly roofing for
control room. Transfer aggregates using dt. Cleaning silting pond
using backhoe. Vulcanized conveyor belt. Hot works and
maintenance. Update DPM and IMS. Loading/ hauling of
aggregates for requirements internal/ external client
2. Awareness on covid19, social distancing, and wearing mask is a
must
3. PROPOSED CHANGE SET UP OF SANDVIK AND HST250 AND VIN
FEEDER if approved by top management. .
4. Check electrical parts of HST250

PTW #: PLA-2018-001-SFT-PTW-1048
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
 Awareness of spotter or helper on lifting heavy parts 
HARD HAT  SPECTACLES
 Available service in case of emergency.
 Proper coordination of spotter and the operator of BH/crane; 
 Always check area, cable wire , shackle before lifting heavy parts 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): ______Ronnie Ignacio______________________ Signed _______RIGNACIO_______________ 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.
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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 ____RIGNACIO_____ 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