TO FILLED BY USER PERMIT lRequineo| GAS TEST ‘AUTHORIZATION AND PERMIT CLOSURE 3 2 E 5 ° 8 3 2 z Zz Q 8 = & 4 3 i = ACKNOWLEDGEMENT [Work Order No. [oate of ise: luseR’s company name: NCC Total Work Man: wit be commence on Date: OY |t2-[26 22,Time:6p 9p ry Work will end on Date: 6.¢ | jog atime bs fey sPeciric AREA: Johe’l Cor Loh downs 8 bescrPtion ret ee ; ser’ Receiving Authority Nom i Signatur o> pate OH] n [os | the recetingauthortys response to ensue the hed peformedintine withthe menionedequrd Stet recatons Disregard wl be sublet to inary actos Activity Persons invoWved in the Radiography leeq_— [mv indium a2 | 76) oO [cobalt 60 [caesium 137 Decay Table tobe provided —_(." w other safety Requirement Nuclde source sa, work matnod statement sth olinatortobe ves? isting it tobe instal around the area? ive he safety sin to be installed round the area? sth emergency resporse plan vale before te work commence? other reauirement Safety Helmer Safety hoe Telosure dan Respiratory protection safety Glasses (white) Double Lanyard Face shield [Shields Ear Protection FRC Coverall [Working Gloves Raciation meter Dosimeter stand by person saricaded tape others Nor Representative Name igatre Date [ADDITIONAL SAFETY MEASURES REQUIRED: : TiotWorkP.No- | cold workP: No [Excavation WPNO| Radiography W.PNo. [SAR No | Method statement et No om = - Oo Neel Nn ir ka a Ta GT TS DO TER OTE Tax [Owens [as in) [Other (Deer %_| ones ‘Gomt_| Oem) | ohertOoree | tame Tat ae aT ace al ee Te ve Crna aw UES SOO Sign: [Contractor Issuing Authority: Wark area has been verified and the required controls measures to perform the task safely _ # are inplaced. Name ia Signature Time A Date:_0 [Contractor HSE Manager/In-Charge: Name. S Signature Time: L ‘ LED a vate 2 Nal tom: Date _O' Jir-[ny ap. Time: 2 Dopry Vaid Up To:date _ 0. a tine: _ fsa ei ‘1 (ei | uncetstand the precaution tobe taken as described aboved user's Receiving Authority: Name signe WYOE Fore: om 12- 42] ‘Thetasr competed andthe warkarcals | The shehas been Greed ardworkarealssafe ] The work area has been checked and accepted property ranged and made sate Users Recoung utory senate Conese SE Rereetae snr virco ing hua etre