SUPPORTING CERTIFICATE OF

PHYSICAL ISOLATION
FORM 3103 REV 2

BRANCH POSCO - CILEGON SERIAL No.

Section 1

LOCATION OF PIPE
WORK OR
EQUIPMENT
Section 2

WORK TO BE DONE

Section 3 Permit to Work Number

RELATED PERMITS
Permit Date

Section 4 Hydraulic Pressure YES/NO Cold/Hot Temperature YES/NO

REASONS FOR Pneumatic Pressure YES/NO Corrosive/ Toxic Gas YES/NO
ISOLATION Confined Space YES/NO Flammable Gases / Liquid YES/NO
(Delete Yes/No as applicable)
Oxygen Deficiency YES/NO Other (State) YES/NO
Oxygen Enrichment YES/NO
Hazard Factor Method of Isolation
Section 5 Step 1: Using the Physical Isolation Selection Tool
CONTROLS indicate the calculated Hazard Factor and method of isolation
recomemded.
Step 2: Can this method of isolation be achieved? YES/NO
Step 3: If NO, refer to SHE Manager or Process Safety Mgr record actions taken Competent Person Referred to:
(Delete Yes/No as applicable)
Step 4: Valve/ Spectacle Plate/ Blank Identification. Padlock Serial Numbers

System Depressurised YES/NO System Purged? YES/NO

Emergency procedures agreed in event of isolation failure? YES/NO Isolation Proved? YES/NO
Section 6 Permit to Work Number
CERTIFICATE ISSUE Authorised Person's Signature

Date
Time
Section 7 Permit to Work Number
CERTIFICATE Authorised Issuer's Signature

RECIEPT Date
Time
Section 8 Permit Issuer's Signature: Authorised Person's Signature:

CERTIFICATE
CANCELLATION Date: Time Date: Time: