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ESP # SUB515001

BLINDING CERTIFICATE CERTIFICATE NO.

GENERAL DETAILS

Date Submitted: _____________________________ Project of Work Order No.__________________________


Equipment Name:____________________________ Equipment No:________________________
Location/Unit:_______________________________ Exact Area Limit:______________________

NOTE:
The performing authority is responsible for inserting and removing the blinds.
The area issuing authority is responsible for witnessing the operations.
BLIND LIST
Details Badge No. / Signature Badge No. / Signature

ISOLATION BLIND SIZE / Date In PERFORMING AREA ISSUING Date Out PERFORMING AREA ISSUING
BLIND NO. LOCATION / LINE
TAG NO. RATING AUTHORITY AUTHORITY AUTHORITY AUTHORITY

Blinding Sketch

Area Approving Authority (Name & Sign): Performing Authority (Name & Sign):

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