0 ratings0% found this document useful (0 votes) 421 views1 pageEnergy Isolation
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content,
claim it here.
Available Formats
Download as PDF or read online on Scribd
Ste ENERGY ISOLATION CERTIFICATE
ASIA. dniting Pte Ud.
Isolation Certificate No.
ORR
14 [ise Location:
1.2 | Work Description:
1.3 | Equipment to be Isolated:
ESE
2.1 ELECTRICAL ISOLATION
Fuses Withdrawn, ‘Action. Tagged Out
Humber [Amps Location Breaker # Padlock No,
‘OPEN | LOCK YES NO,
‘OPEN | LOCK YES NO,
‘OPEN | LOCK YES NO,
‘Other Precautions Taken:
Thereby confirm the above isolations and precautions have been taken, the equipment has been proven de-
energized by electrical test and all concemed / affected individuals have been adequately informed.
Name of competent person performing isolation Signed
Date: «Tire
2.2 OTHER TYPES OF ISOLATION
‘Control Inlet Outlet | Lines. Valves
Mechanism Location Drain Bianked | OPEN croseo | Padlock No. Tagged Out
17070] ves NO__| OPEN | CLOSED YES NO
[O00 | ves |_no_| OPEN | cLoseo YES. NO
too] ves NO | OPEN | CLOSED: YES NO.
Other Precautions Taken:
Thereby confirm the above isolations and precautions have been taken, the equipment has been proven isolated
by test and all concerned / affected individuals have been adequately informed.
Name of competent person performing isolation: Signed:
Dat Time:
Name of Responsible Person authorizing Isolation:
Signed: Date! Time:
3.0 RECEIPT OF CERTIFICATE BY PERSON IN CHARGE OF WORK
‘acknowledge receipt of a copy of this certificate and understand that the equipment has been isolated and is safe to work
Ihave personally checked that the correct equipment has been isolated.
2) Signed Person in charge of work Time: Date:
b) Signed Person in charge of work Time: Date:
©) Signs Person in charge of work Time: Date:
Handover a8 required: (i work is continuing after shift change, isolation must be referenced in Shift handover report to reel,
Teas
Thereby confirm that the work detailed in section 1 above is completed, the personnel and equipment withdrawn and the
Isolation may now be removed by a competent person responsible for the de-solation.
Person in charge of work Time: Date
a)Signed__
EXXON a
Thereby confirm that the isolations detailed in section 2 have been removed and the system re-engergized
a) Signed: Competent Person Time: Date
b) Signed: Competent Person Time’ Date:
ee
Term Isolation”. Ihave placed the equipment isolation keys and a copy of this certificate in the “Long Term Isolation Box”.
a) Signed: Person in charge of work Tine: Date:
b) Verified by: Responsible person Time: Date:
