Ref. No.

BQP-F-HSE-24
Rev. No: 2

PERMIT TO WORK Date: September 5, 2023

(Excavation) Page(s) 1

Date : PTW :
Method Statement Ref No :
_________
Work begins at : : h AM / PM PTW Expires at ______________:h AM / PM
__
Short description of the work:
A permit is required for all excavation work more than 1/2 meter deep

A permit is required for any excavation in the vicinity of elecrical installation, water installation, etc.

CHECKLIST N/A* YES NO

1. Is the work Risk Assessment and / or JSA compliant?
2. Adequate lighting?

3. Barriers / safety signs in place?

4. Swing area of excavator free from people / obstacles?

5. Overhead structures ?

6. Pedestrians not allowed / separated from the work location?

8. Edges / slopes stability known. Operator knows eventual hazards?

9. Cables and pipes or other underground hazards known and protected?

10. Operator instructed sufficiently?

11. Toolbox talks with the others involved? (must be attached with this PTW form)

12. Proper Personal Protection Equipment (ear/eye/respiration/high visibility/shoes/hardhat)

13. Interfaces with others sufficiently checked / communicated?
14. Other precautions?

AUTHORIZED PERMIT ISSUER (Engineering Dept.)

: Name
: Signature

AUTHORIZED PERMIT RECEIVER / PERMIT HOLDER (worker /Contractor )

I, the undersigned acknowledge that all the above items are inspected and adequately implemented before start of the work.

: Name

: Signature

PERMIT APPROVING AUTHORITY / COORDINATOR (HSE Officer)

Name : Signature: Time:

PERMIT EXTENSION (Supervisor's handover)

The permit can be extended one shift only. Handover to next supervisor (name)
Checked all mitigation measures are still adequately in place:
Signature:

Date: Time : PTW finally expires at:

CLOSE-OUT
New permit required to continue the work Yes / No*
Authorized Permit Receiver / Permit Holder (Supervisor).

Name: Signature:

Remarks (if any) by Authorized Permit Issuer:

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