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. BATCH READY MIX CONCRETE DELIVER
Work Item/Activity:
Location/Area: 7-0 Brgy Mamatitang Contact #: 09984499126
GOODS (INCLUDING AGGREGATES) AND SERVICES.
Name of workers: Brief Description of Work / Activity (Include equipment, tool or materials to be
ALL PLANT CREW AND DRIVERS_____ used):
OFFICE STAFF____________________ 1. Batch ready mix concrete, using central mixer wet type, cleaning
GUARD ON DUTY_________________ central mixer confined space. Deliver of goods and service using
truck mixers and DT for aggregates supply. Hot work, work at
heights welding machine and cutting set, loading aggregates into
hopper bin using pay loader applied 5’s within working area.
Conduct daily preventive maintenance and update IMS. Rehab of
spare sicoma twinshaft mixer Receiving and unloading delivery of
river sand/lahar, aggregates, cement bulk, admix. Vulcanized
conveyor belt if any. Unloading aggregates from hopper using dt if
any. Implement social distancing. Awareness on covid19, and
wearing mask is a must. Renewal of self declaration form and
medical certificate depends on EHS guidelines

PTW #: PLA-2000-002-SFT-PTW-1227
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
 Buddy/watcher during operations, during working at confined space 
and at least 10-15 minutes rest interval HARD HAT  SPECTACLES
 Available service in case of emergency. 
 Available stand by fire extinguisher at the area; SAFETY VEST RESPIRATORS
 Awareness and coordination of plant crew and operator during 
operation of ready mix and working at heights. FACESHIELD EARPLUG/EARMUFFS
 Informing superiors in case of emergency 
 Report all possible unsafe condition tools/equipment/machine/and FACEMASK ENGINEERING (Specify):
others before working; Avoid using of improvised hand tools  GLOVES

PART E. OTHER SAFETY MEASURE/S RECOMMENDED (To be filled up by SAFETY SHOES
Safety Officer):

DECLARATION I understand will follow the precautions to be taken under this permit.
Name (Print): ______Lemuel Dela Cruz_________________ Signed _______L DelaCruz______ Date _11.02.22_______
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 ____ L DelaCruz _____ 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