SECTION HSSE

STATUS CONTROLLED

COLD WORK PERMIT REFERENCE PPC/HSSE Permit 002

‫شركة التغليف الرئيسة‬ REVISION 0 DATE 11/04/2019

Premier Plastic Company SHEET 1

BUSINESS UNIT :
DATE
PERMIT FOR (Company) : PERMIT NO. :
APPLIED :

SECTION I:

Location of work: ______________________________________________________________________________

Description of work: ____________________________________________________________________________
Approx. duration of work: From(time) ____________ am/pm To(time) ______________ am/pm
Name of task in-charge: _________________________________ Phone No. : ____________________
Required documents: Method statement: Risk Assessment:

SECTION II (Precautions to avoid potential hazard):

1. Pre check has been done for the area; free from combustibles and area barricaded. Yes / No / NR
2. Is the equipment electrically isolated and tagged. Yes / No / NR
3. Electrical clearance permit # ___________. Yes / No / NR
4. Is the equipment depressurized, purged and flushed. Yes / No / NR
5. Ventilation sufficient. Yes / No / NR
6. Protection provided for other workers and property. Yes / No / NR
7. Operator is trained and competent. Yes / No / NR
8. Operatives are in possession of the PPEs specified for the task. Yes / No / NR
9. Have all the valves been closed/opened. Yes / No / NR
10. Is the equipment under pressure or hot. Yes / No / NR
11. Have the units been affected by the work been notified. Yes / No / NR
*NR - Not Relevant

SECTION III (Permit requested by): Task In-charge

 Maintenance
 Production
 Others (Specify) ______________________________

I request for a permit for the above mentioned work at the location specified above. I have personally inspected the
work place to ensure that requirements needed as precautionary measures as mentioned above have been complied
with.
Name (Person Requesting): ____________________________ Signature: ______________ Time: _____________

PPC/HSSE/HTWP Form/004/2/Rev 0 Dated 11th April, 2019

SECTION HSSE
 STATUS CONTROLLED
REFERENCE PPC/HSSE Permit 002
COLD WORK PERMIT
REVISION 0 DATE 11/04/2019
‫شركة التغليف الرئيسة‬
Premier Plastic Company SHEET 2

SECTION IV (Permit issued and authorized by):

Work shall be carried out (only) after complying with the requirements of section II and the following Signatures below.

This is valid up to (Time): ______________________________________ Date: __________________

HSSE In-charge: Name __________________________ Sign. _________________ Phone ______________

Plant Manager: Name __________________________ Sign. _______________ Phone ______________

SECTION V (Extension of Permit):

We approve the extension of the above work after personal inspection, conditions mentioned in Sec. II are ensured.

From: _____________________ hrs. To: ________________________ hrs.

Requester: Name _________________________________ Sign. ________________________ Time _____________

Issuer: Name _________________________________ Sign. ________________________ Time _____________
Authorizer: Name _________________________________ Sign. ________________________ Time _____________

SECTION VI (Closing of Permit):

The work is completed and the area has been cleaned.

Name (Person Requesting) _______________________________ Signature ________________________

(Name as in Section III)

Time ____________________ Date ____________________

To be returned to the HSSE Department after completion of work and duly closing.
Names of the persons involved in the task to be briefed by Supervisor and HSE Personnel:

PPC/HSSE/HTWP Form/004/2/Rev 0 Dated 11th April, 2019