PRIMARY WORK PERMIT CONTROL NUMBER:

Project Proponent / Name HSES P.R # or WR #

Name of Contractor: BRAVOCYCLE TRUCKING AND HAULING SERVICES

PROJECT TITLE GARBAGE HAULING Name of Contractor Safety Officer/: LUTHER N. ESCALADA, JR

Project Engineer:

JOB SAFETY ANALYSIS  Use separate sheet for accomplishing Job Safety Analysis Worksheet. ( HSE-F-15 )

Specific Wok Location:

Location of Work: SOUTH HARBOR MANILA (highlight attached ATI map)

Type of Work: Electrical Mechanical Civil Others (specify): _________________

Description of Work; Construction

Particulars HAULING OF GARBAGE

Date Work to Start: Expected Date of Completion: This Permit is valid for 15 days only

1.          ANDRES BANILLA 5. MARK DANAO 9

2. ROEL CANTORIA 6. WILLIAM ONG - SO3 10

Name/ list of Contractor's personnel
at site:
3. JAYR CANTORIA 7. LUTHER ESCALADA, JR. - SO3 11

4. JAMES TROMPETA 8 12

CHECKLIST ON WORK REQUIREMENTS

(Project Proponent shall ensure below checklist is completed before Work Permit is issued)

A
OTHER PERMITS/FORMS REQUIRED
? YES ( Tick below that applies) NO  PRIOR TO START OF WORK

Hot Works Excavate Penetrate CONFORM APPROVED BY

Lock-out/ Tag-out (Isolation) Project proponent
Confined Space Entry
(Electrical, Pneumatic and Hydraulic) Contractor Engineering - FED
Area in charge HSES
representative:
Hazardous Substance Responsible BU
High Voltage Access
Fire Protection, Detection Equipment
Working at Height
Impairment Notification systems
Others: (specify)

-----------------------------------------------------------------------------------------------------------------

Note: Specific Work Permits are valid for ONE SHIFT only.

Please attach the following:

Equipment Certificate Operator's Training Certificate SDS (if applicable) LUTHER N.

ESCALADA, JR JANICE S. PICARDAL
Print Name Print Name
B GENERAL REMINDERS LIST ( Please check) YES N/A over Signature
Print Name over Signature Print Name over Signature
over Signature

Contractors are aware of the safety requirements on construction

1
work within ATI premises?
ü WORK COMPLETION
Contractors have submitted a construction plan to the Project Attested Approved by
2
Proponent of construction work?
ü

Construction area has been identified to the contractor personnel & Project proponent
3
that proper separation /enclosure are installed?
ü Contractor representative:
Engineering-FED Responsible Business Units

Contractors have agreed to keep good housekeeping within the

4
identified construction site?
ü
Contractors confirmed that signages shall be installed prior start of
5
work to warn all personnel of work activities?
ü

6 Contractors have been instructed of Entry or Exit procedures? ü Print Name over Signature Print Name over Signature

Contractors have been instructed on ATI security procedure (bringing

7
of equipment in and out of ATI)?
ü REMARKS :

Contractors have understood the HOT WORK PERMIT

8 requirements, if there will be any hot work activity in the course of ü SHIFT MANAGER/CTD -
construction work?
Contractors have agreed that HOT WORK PERMIT is required
9
before doing any hot work activity.
ü SHIFT MANAGER/GSD -

Contractors have understood the need for observing fire preventive

10
measures and prohibits the use of fire without approval?
ü OLIVER ACLAO/ADMIN -

Contractors are aware of the reporting procedures in case of

11 accidents/incident in ATI premises during the course of construction ü
work?
Contractors have agreed to park equipment or vehicles at designated
12
areas approved by ATI Security?
ü

Contractors have confirmed that they are not to allowed to impair

protection equipment by themselves? They shall accomplish the
"Fire Protection, Detection Equipment Impairment Notification
13
Systems form" if activities will impair or affects fire protection/
ü
prevention systems (i.e automatic suppression systems, fire
sprinklers, fire pump, etc)

Prior to start of work, distribution/recipients include:

ORIGINAL copy : Contractor Copy 2 : HSES CC: HSES shall furnish a copy via e-mail to Project proponent / BU concerned / Security

HSE-F-08, rev. 05 , 01 April 2023

Record retention: Project completion + 3 Years
 INSPECTION MONITORING
Name of Contractor Description of Work
Contractor Representative Location of Work
Target Completion
Start Date:
Contractor Safety Officer Duration of Work Date:

Area Owner Project Proponent Contractor's Safety Officer

Day Date Time of Time of Time of
Name Signature Name Signature Name Signature
Inspection Inspection Inspection
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

HSE-F-23, rev. 01 , 01 April 2023

Record Retention : Project completion + 3 Years