Annex VIII – Temporary Issuer Assignment REVISION 1.

2020

Responsible for filling out: Identification Number: Signature: Date:

Why SWP cannot be issued by the actual issuer of the area?

1 - Temporary Issuer
Vale employee (will not participate in task performance) ☐ YES

Third party employee (contractor from independent company; will not participate in task performance) ☐ YES

Name: Identification #: Company:

Applicable qualification and training:

2 - Activity Objective / Scope

Physical limits of work:

Interfaces and isolation measures:

Appointment period: from: ______/______/______ to: ______/______/______

3 - Status of area/equipment to be assigned to temporary issuer

Isolated YES NO*3 NA
Shutdown YES NO*3 NA
Not in operation YES NO*3 NA
Deenergized (lockout/tagout)*1 YES NO*3 NA
Clean*2 YES NO*3 NA
Physical connections with process duly disconnected YES NO*3 NA
Interconnected waste collection systems duly checked out to prevent the area from being impacted YES NO*3 NA
by spot or continuous discharges from adjacent areas?

Have all utilities lines (air, electricity, pressurized water) that must remain pressurized during appointment period been formally released by
area leadership to be used and identified on site differently from the other ones?

YES Which? ___________________________________________________________________________________________________ N/A

*1 all active, potential and residual energies duly identified and locked/tagged out – zero energy
*2 decontaminated and having no residual process byproducts

*3 For each NO, one or more control measures must be addressed and duly recorded in NOTES field of this Document and on the ART

4 - Notes

Exceptionally Appointed Temporary Issuer's signature:

Signature of Area Manager appointing Temporary Issuer:
Signature of Manager/leader of employee acting as Temporary Issuer: