nomor izin:

IZIN MEMASUKI RUANGAN NI02.SBE.02.24.00072

Status:
TERBATAS PRG

1 – Pengajuan Pekerjaan
Persiapan Izin Work to Perform

Tanggal/Waktu pengajuan: 03 February 2024 / 08:00 Title: (SBE) REPLACE STRAINER RVDF
Description: (SBE) REPLACE STRAINER RVDF, MENGGERINDA DAN
Spesifik lokasi kerja/peralatan: PRODUKSI MESIN RVDF PENGELASAN STRAINER
Requested Entry Time: 08:00 to 03:00
Nama pengawas pemilik area kerja:
Number of Entrants: 4
No Nama Jabatan Name of Workers (In Full)

1 PAK ALDI Asst. Supervisor No Nama Lengkap Role

2 PAK ALDI Asst. Supervisor 1 PAK WAWAN SPV

3 PAK ALDI Asst. Supervisor 2 PAK REZA FOREMAN

Particulars of Requestor 3 PAK REZA FOREMAN

Company name: (BKS) Berkah Kawan Setya 4 PAK DIDIK FITTER

Requestor name: (Hanief) Hanief Prasetyo Designation: Maintenance 5 PAK RIZAL HELPER

6 PAK EDO FITTER 2

Hot Work Equipment/Tools
Additional Working Permits/SOP Required:
No Jenis Jumlah Kondisi Keterangan
Hot Work Permit Working at Height Permit
1 Full body harness 2 PC Baik
Cold Work Permit Electrical Work Permit
2 Sepatu pelindung 2 PAIR Baik
Lockout Tagout Permit Heavy Lifting Work Permit
3 Sarung tangan 2 PAIR Baik
Confined Space Entry Permit Excavation Work Permit
4 Kacamata pelindung 2 PC Baik

5 Tali 1M Baik

6 Derek/katrol 1 PC Baik

7 Pelindung kepala / helm 4 PC Baik

8 Blowers 1 PC Baik

9 Masker debu / respirator 1 PC Baik

10 Gas detector - personal monitors 1 PC Baik

11 Alat komunikasi (radio, senter, peluit) 1 PC Baik

12 Peralatan keadaan darurat (tandu, kotak P3K) 1 SET Baik

2 – Hot Work Preparation Steps & Precautions

Job Safety & Environmental Analysis (JSEA) Isolations Required

JSEA reviewed and approved. (Reference no.: jsea-1705996483.pdf) Perpipaan (Air, Steam, Gas, dll) Penggerak Mekanik/ Elektrik Energi Listrik
Control measures implemented and verified by Permit Authoriser / EHS Officer Sistem Pemadam Kebakaran Instrumentasi Lainnya
High Risk Activity – Hot Work Permit Checklist reviewed (attached) Lainnya

Decontamination Ventilation Required

Pengeringan Pembilasan/ Pembersihan dengan Steam Alami Minimum ventilation for entry without
Breathing Apparatus, If safe to do so, is 4
Pembersihan ditempat (Clean in Place) Pemeriksaan Laboratorium Suplai udara positif dengan alat bantu
times the volume of the confined space,
Exposure to Other Contaminants (Refer to Sec. 8 of individual SDS) Pembuangan udara dengan alat bantu for a large storage tank this could be
Aliran udara sllang (Masuk dan Keluar) several days. Seek assistance if unsure
Hazardous Substance Name Acceptable Limit (TWA/ STEL)
how to calculate this.
- -
Stand-by Person & Rescue Plan Required
Initial Gas & Atmospheric Testing
* Record additional readings on the HWP supplementary sheet Rencana tindakan penyelamatan & darurat dipahami dan dipajang
Fasilitas penyelamatan dan komunikasi tersedia di lokasi
O2 (19.5-23.5%) 20.5 % Testing Frequency:
Personil jaga
CO (<30ppm) N/A Continuously
Personil jaga
H2S (<10ppm) N/A Periodically
Nama personil tanggap darurat
LEL (0%) N/A
Nama personil tanggap darurat
Gas Tester 02 Feb 2024
Calibration Date: Nama personil tanggap darurat

Gas Tester Model - Nama personil tanggap darurat

Gas tester S/N# - Additional Precautions Required

Ventilation OFF >15 mins. Prior to initial/internal vapour checks - Turn ventilation ON
after initial clearance & BEFORE first entry.
Measuring gas level at different levels inside a Confined Space is required.
3 – Authorisation & Acceptance
Pemberitahuan peringatan/barikade berada di posisinya
Peralatan yang digunakan benar-benar aman (intrinsically safe)
Peralatan komunikasi
Personal gas detector dibutuhkan untuk pemantauan kontinyu
Merokok/minum/makan dilarang
Personil yang masuk telah dilatih dan valid secara dokumen

Permit Valid From:

https://weptw.wilmar.co.id/permit/print_2?pwi=NTY2MDA=&p A==&pnum=ODg4NDk5&pg=c2VhcmNo&ia=OTY1NDUxMw== 02/02/24, 17.05

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 Permit Valid From: Date: 03 Feb 2024 Hours Permit Requester Signature: I accept this CSE permit and agree abide by the
conditions stipulated. I will instruct all entrants on
From: 08:00
the Hazards and Risks and ensure all controls
Maximum for one shift remain in place until the work is complete.
To: 16:30
only
Permit Accepted by: (Permit Receiver – Wilmar supervisor/ technician/ engineer only/ Maintenance Manager)

I accept this Hot Work Permit and agree to abide by the conditions stipulated. I will instruct all workers on the Hazards and Risks and ensure all controls remain in place until
the work is complete.

Name: (subali) Subali Subali Date: 02 Feb 2024

Signature: (Approved)
Position: MTC - Fabrication Time: 14:25

Name: (aldirifqi11) Aldi Rifqi Hidayat Date: 02 Feb 2024

Signature: (Approved)
Position: Plant Responsible Time: 13:06

Name: (nesiaimaselfi) Nesia Imaselfi Date: 02 Feb 2024

Signature: (Approved)
Position: Safety Officer Time: 10:09

Permit Authorised by: (Plant/ Factory/ Project)

I certify that I have personally examined this application, the hot work risk assessment, the rescue plan, the work area, checked all precautions, tools and equipment and I am
satisfied the controls are in place and authorise hot work to commence.

Name: (diansiregar) Dian Siregar Date: 02 Feb 2024

Signature: (Approved)
Position: Head Department Time: 17:04

4 – Completion and Permit Clearance

THIS WORK IS COMPLETED/ SUSPENDED BY: THIS PERMIT IS CANCELLED & CLOSED BY:
Completed Suspended/Been Suspended All Personnel & Tools are accounted for and site is secured.

Permit Authoriser:
All Personnel & Tools are accounted for and site is secured.

Action log: N/A

Permit Receiver:

https://weptw.wilmar.co.id/permit/print_2?pwi=NTY2MDA=&p A==&pnum=ODg4NDk5&pg=c2VhcmNo&ia=OTY1NDUxMw== 02/02/24, 17.05

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