ANNEXURE-VI (B)

WORK PERMIT (For issue by Officer of the Oil Company or Company Authorized
Person)

(Name of Company) Name of the RO / Location

Sl. No-01 New B-Site KSK/CHAKIA

Date AM / PM Date AM /PM.

Valid from -15/03/2023 / 09:30AM Upto. 15/03/2023 / 05:00 PM

Note: This permit shall be valid for the above specified period not
exceeding 15 days.

Permission is granted to section or contractor

KIMSON ENTERPRISES

Nature of work in detail for which this work permit is valid.

EXCAVATION FOR 20KL TANK , BRICK FOR TANK PIT , ISLAND ,

PIPELINE WORK

location of work (specific area inside the RO)

NOC AREA___________________________

The following items shall be checked before issuing the permit (Please
put tick [ ] mark in the appropriate box)
Sr. No. Item Done Not Required
1 Equipment or Work Area inspected DONE
2 Surrounding area checked, cleaned, and DONE
covered (ensuring product is not exposed to
atmosphere in the working area)
3 Identify the Equipment to be repaired and switch DONE
off its electric supply (equipment electrically
isolated and tagged)
4 Portable extinguisher and sand buckets provided ] NOT
REQUIRED
5 Blocking of sources of product or vapour in pipeline ]
NOT
or tank or equipment (equipment blinded or REQUIRED
disconnected or closed or isolated or wedge opened)
6 Removal of left-over product in Tank or pipeline ] NOT
REQUIRED
or equipment taken up for works
7 Equipment water Flushed ] NOT
REQUIRED
8 Pyrophoric Iron removed or kept wet DONE ]
9 Proper ventilation and lighting provided ] NOT
REQUIRED
 10 Gas test done, found gas free DONE ]
11 Standby personnel provided DONE ]
(confined space entry viz tank entry and like other
entries)

SPECIAL INSTRUCTIONS

Following personal protective equipment are required (check all items required)
existing list of PPE plus one more item “Safety Harness” to be added in the list.

1. In case of fire alert, all work must be stopped. All personnel must leave work site and
proceed to designated or on site directed areas.
2. Remarks on toxic/hazardous chemicals, if any.
______N/A_________________________
3. Alternate means of escape available or provided or not required.
4. This permit must be available at work site at all times.
5. Additional items, if any:
________N/A______________________________

I have duly explained the nature of the work, risk involved and all the safety
precautions to be followed to the vendor and his supervisor for implementation, as
well as to the dealer and his authorized representative for monitoring the same. This
permit shall be valid till the work as mentioned in “Nature of work” is completed.

Name and NASINGH MOURYA MANAGER.(ENGG)

Signature of Officer or/ Company Authorized Person._____________________

I Have Understood The Risk Involved And The Safety Precautions Explained To Me
By The Oil Company Officer Or Company Authorized Person And I Shall
Monitor The Work In Accordance With The Same Till The Work As Specified
Under The “Nature Of Work” Is Completed.

Name And – ASHWANI TRIPATHI

Signature Of Dealer Or Authorised Manager._________________________

I Have Understood The Risk Involved And The Safety Precautions Explained To Me
By The Oil Company Officer Or Company Authorized Person Or Dealer /
Dealer’s Authorized Manager And I Shall Carry Out The Work In Accordance
With The Same, Till The Work As Specfied Under The “Nature Of Work” Is
Completed.

Name And- SANJAY KUMAR SRIVASTAVA

Signature Of Contractor Or Authorised Supervisor.________________________

List of activities for which permit annexure VI(b) to be Filled:

 Repair Or Rework Or Cleaning On The Tanks And Pipeline Work

 Tank Removal Or Decommissioning.
 Non- Routine Maintenance Or Replacement Or Major Electrical Work Within
Hazardous Area.
 Oxygen Deficiency Or Inert Gas Entry.
 Pneumatic Or Hydrostatic Pressure Testing.
 Oil Interceptor (Like Oil Or Water Separator And Like Other Interceptor)
Cleaning.
 Where Entry Into The Interceptor Is Required.
 Hot Work Including But Not Limited To Welding Or Grinding Or Gas
Cutting.
 Demolition Or Revamping.
 All Activities Capable Of Producing A Spark Inside A Hazardous Area.
 Excavation Including Forecourts Exceeding 1 Feet Depth
 Concrete Cutting In The Hazardous Zone.
 Setting Up Of Temporary Equipment Including Product Recovery Equipment
 E.G. Compressor, Water, Or Sand Blasting Equipment And Like Other
Equipment.