Scribd
Upload
316 views2 pages

Permit To Work

This document is a permit to work that outlines the requirements and approvals needed for servicing underground tanks at a fuel station. It requires details of the work, hazards identified, risk controls in place, personal protective equipment requirements, and sign off from the work leader, receiving authority, area authority and approving authority representative. The permit emphasizes that no work is so urgent that safety cannot be taken into account.

Uploaded by

Muhammad Haziq
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
316 views2 pages

Permit To Work

This document is a permit to work that outlines the requirements and approvals needed for servicing underground tanks at a fuel station. It requires details of the work, hazards identified, risk controls in place, personal protective equipment requirements, and sign off from the work leader, receiving authority, area authority and approving authority representative. The permit emphasizes that no work is so urgent that safety cannot be taken into account.

Uploaded by

Muhammad Haziq
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

PERMIT TO WORK

NO WORK IS SO URGENT,
THAT WE CANNOT TAKE TIME TO DO IT SAFETY

SECTION 1 : REQUISITION
Applicant’s Name Department Contact No
(PROTON) (PROTON) (Mobile)
Site Supervisor
MUHAMMAD HAZIQ ZABALUDIN
Company HABLEM OIL & GAS (M) Contact No 018-2304494
(Contractor) (Contractor) SDN BHD (Mobile)

Description of Work : To Service Underground Tank and Fuel Interceptor Tank at Fuel Station at R&D Start Date : 16/1/2023

Work Location : Fuel Station RND Finish Date : 16/3/2023

Other Permit Hot Work Permit Working At Height


Required : Confine Space Use Of Crane

SECTION 2 : HAZARD & IMPACT IDENTIFICATION

Schedule Waste \ Flammable Operating Machinery Air Pollutant Height


Domestic Waste Toxic Hot Surface Crane Others :
HAZARDOUS Contr` Waste Corrosive Moving Equipment Buried Services
\ Dust High Pressure Waste Water Land Contamination
Hot Road Traffic Lifting Interlock by pass
Noise Scaffolding Excavation Steam

SECTION 3 : POLLUTION & RISK CONTROL

Fence Safety Plug Protection Circuit Shut of Power


ENGINEERING Protector Safety Latch Switch Separation Partition
Control Devices Safety Valve Storage Route
Log Out Tag Out Ventilation Fire Extinguisher \ Spillage Kit

\ SHE \ Work Permit Labling Waste Water Mgmt SOP


ADMIN \
Training Safety Briefing Competency Equipment Approver
CONTROL
Warning Sign \ Inspection ISO 14001 Awareness Schedule Waste Management Briefing

PERSONAL Face Shield \ Safety Shoes Safety Harness Filter Respirator \ Others :
PROTECTIVE Eye Goggle Catridge Mask \ Lather/Cotton Glove Chemical Resistance Suit Face Mask
EQUIPMENT Ear Protection Paper Mask \ Bump Cap/Safety Helmet Chemical Resistance Glove

SECTION 4 : REQUEST & APPROVAL


WORK LEADER / CONTRACTOR (WL) RECEIVING AUTHORITY (RA)
I understand that it is my responsibilility to susure that all persons engaged in
I have personally checked the area and equipment to be on I am satisfied the
work executes their duties in a safe manner in accordance with the requipment
work requested can be carried out safety
of this permit

Signature : Signature :

Name : MUHAMMAD HAZIQ BIN ZABALUDIN Name :

Date : 5/1/2023 Date :

SECTION 5 : ACKNOWLEDGEMENT
AREA AUTHORITY (AA1) APPROVING AUTHORITY REPRESENTATIVE (AAR) SHE
Signature : Signature :

Name : Name :

Date : Date :

1
SECTION 6 : SAFETY COMPLIANCE CHECKING
No Non - Compliance Date Time Name Signature
1

10

SECTION 7 : PERMIT EXTENSION (IF ANY)

Duration (No of day) Date of Extension

Reason for Extension :

WORK LEADER RECEIVING AREA AUTHORITY APPROVING AUTHORITY

Signature Signature Signature Signature

SECTION 8 : HAND BACK

1. Work Completed Yes No 4. Waste Management Yes No

2. Housekeeping Completed Yes No

3. Incompleted hand back ( Equipment status, reason for hand back, etc ) :

SECTION 9 : COMPLETION AND PERMIT SIGN OFF


APPROVING AUTHORITY
RECEIVING AUTHORITY (RA) AREA AUTHORITY (AA1)
REPRESENTATIVE (AAR) SHE
Signature: Signature: Signature:

Name: Name: Name:

Date: Date: Date:

You might also like