BI# 10-00875

Relocate Jazan-Abha Refined Products Pipeline SICIM SAUDI ARABIA

Contract # 6600045122
COLD WORK
WORK PERMIT NO #
PERMIT

Month Day Year Duration

Section-1 – Work Description

Identify Plant/Facility (where work will be carried out)

Exact work location

Work Description

Equipment to be used at site

STOP WORK if job site does not meet work permit conditions or any applicable Saudi Aramco Safety & Health requirements at any time

Section 2 – Hazard Identification and Control

A. Identify and attach any supplementary forms required to perform/control the work
 Method Statement  Critical Lift Plan  Pre-Excavation Checklist  Excavation Checklist  Job Safety Analysis
B. Energy Types
 Electrical  Mechanical  Hydraulic/Pneumatic  Hydrocarbons  Others
C. Potential Exposures
 High Noise  Temperature  Hydrogen Sulfide(H2S)  High Wind  Hazardous Material
 Radioactive Material  Flammable Liquids/gasses  Others
D. Protective Equipment
 FRC  Fall Protection  Personal H2S Monitor  Goggles/Face shield  Hard Hat 
Clothing
 Safety Shoes  Barricades  Respiratory Protection  Warning Signage’s  
 Standby Man  Firewatcher  Flagman  Confined Space Entry Supervisor
Badge# Badge# Badge# Badge#
E. List any additional safety requirements

IN CASE OF EMERGENCY :

Section 3 – HAZARD ANALYSIS CHECKLIST

N/
Y N Y N N/A
A
Is the correct type of permit issued for the work    Are slip trip and fall hazards controlled   
Are weather conditions( wind speed , temperature) Have all the requirements of work at height
     
acceptable to perform the work been applied
Does the crew know what to do in case of emergency    Are all ignition sources eliminated or controlled   
Does personnel have proper certifications to perform Is the scaffold tag completed correctly, signed
     
activity/equipment/device and with a valid inspection date
Is the equipment’s inspection sticker valid    Is the correct PPE available for the personnel   
Does the work crew have the correct tools/equipment Does the fire watch have firefighting equipment
     
for the job? are they in good condition available and know how to use the equipment

Section 4 – Gas Testing/Monitoring

LEL (%) H2S (ppm) O2 (%) GAS TESTER NAME CERTIFICATE No. SIGNATURE
Initial Test

Additional

Section 5 – Permit Authorization & Closure

PERMIT RECEIVER PERMIT ISSUER
CERTIFICATE CERTIFICATE
PERMIT BADGE No. SIGNATURE BADGE No. SIGNATURE
No. No.
OPEN
I have inspected the work site and confirm that it
This permit has closed Date Time
has been returned to a safe condition
CLOSED
WORK PERMIT BADGE SIGNATURE
 COORDINATOR No.

JAPL-F-CWP-001