PetroChina (Halfaya) Permit To Work System

ISOLATION CERTIFICATE No.:

I. TASK
Brief description of the proposed task: Work Request Period (Planning)
From Date Time
To Date Time
Work Permit Number: Permit Type Hot Work Permit Cold Work Permit
Equipment Isolation Required
Location: Instrument Electrical Mechanical
(Tick as applicable and explain)
Name (Certificate Originator): Signature & Contact No.: Date Time

II. ISOLATION DETAILS & SUPPORTING DOCUMENTATION

What is to be isolated and what is the purpose? Provide details of the isolations required including location, process and plant/equipment: Supporting Documents YES NO Doc. Number
Marked Up P&IDs
Vessel Drawing
Electrical Scheme
Isolation Drawings
Other, Specify:
III. ISOLATIONS APPLIED / REMOVED
Isolations Applied Isolations Removed
No. Safety Critical? Isolation Test
Date Time Isolation Location Isolation Method Signature Date Time Signature
YES NO Run Completed

10

11

12

13

14

15

16

17

18

19

20

Are all forms of energy de-energised? (Y/N) Are all forms of energy released? (Y/N) Work is complete and all isolations are removed? (Y/N)
Comments: Comments: Comments:

IV. CERTIFICATE APPROVAL AND ISSUANCE

ISOLATION AUTHORITY AREA OPERATOR / CUSTODIAN
I understand the work scope and accept the conditions and precautions specified in this certificate. I will explain them to the I declare that all hazards have been identified and all specified control measures are in place and it is safe to carry out the work defined.
work party through a toolbox talk prior to commencing the work and ensure adherence throughout the work. I fully accept the
responsibility to carry out the above work in the safest possible manner.

Name: Name:
Employee No.: Employee No.:
Signature: Signature:
Date/Time: Date / Time:
V. CERTIFICATE CLOSURE
ISOLATION AUTHORITY AREA OPERATOR / CUSTODIAN
I declare that all Work Permits associated with the isolations on this certificate have been closed, the isolations have been I have inspected the equipment/work area and declare that the work defined in this certificate is complete and that the area is clean and safe.
removed, worksite is clear, housekeeping is satisfactory and the equipment affected is left in a safe condition.

THE ISOLATION CERTIFICATE IS NOW CLOSED

Name: Name:
Employee No.: Employee No.:
Signature: Signature:
Date/Time: Date / Time:
Top Copy: Isolation Authority (To be displayed at job site) Second Copy: Permit Control Facility/CCR Third Copy: Permit Issuing Authority

NOTE: This certificate is valid only when used with a valid work permit. This certificate alone does NOT authorise any task to be performed. Version 2.1 Jan 01 2018