Excavation Permit Ex. Permit No.

:
Main Permit No.:
Duration of work From……………… To………… Equipment to be worked on………………………… Location……………………..
Other Permit (s) required? yes No If yes, write down the required permits……………………………………………
Proposed Work………………………………………………………………………………………………………………………………………………………..
Applicant Name…………………………… Dept……………………………. Date/Time……………………………….. Signature…………………
General Control Ensure drain to be covered safely
 Clear area access permit check electrical isolation by operating local switch
 Provide additional access, ventilation, lighting Fire-gas detection system
 Ensure equipment if free of oil, gas, flammable Inform personnel whom may be affected
 Shutdown, isolate, depressure, drain, flush, purge Provide radio communication
 Post warning sign Fence or Rope off area

Special Precautions approve safe work procedure Additional safety precautions

Underground electrical cable protected marking the exact excavation location
Underground civil work protected adequate access and egress provided
Underground temporary facilities protected secured ladder provided
Underground piping protected
Personal Protective Equipment
Safe belt Eye goggle
Helmet/Boot Face mask
Ear protection Gloves
Breathing protection Ear plug
Safety clothing Others
Lockout/Tagout Application
Electrical Isolation permit required Yes No If yes provide permit No……………………
Mechanical Isolation permit required Yes No If yes provide permit No……………………
Padlock/Card No……………………... Location…………………………
Padlock/Card No……………………… Location…………………………

Declaration
I the permit issuer assure that all the above control measures have been taken and all the above requirements
have been communicated to the permit applicant.

Permit Issuer Name………………………… Date/Time…………………………………… Signature…………………………

I, the permit Applicant, on behalf of myself and my crew understand all the above safety requirements and will
perform the work safely according to these requirements and Sinopec HSE policy and procedures.

Applicant Name…………………………... Date/Time………………………………… Signature……………………..….

Authorization (permit may be issued when all the above conditions have been met. Max. initial period of 12hrs
only)
Permit Approver Name………………………….. Date/Time……………………………….. Signature…………………..……..
Work completion/verification
Permit is extended from………………. Hrs on……………………. (date, d/m/y) to……………hrs on………………… (date, d/m/y)
Permit closed at……………….. Hrs on……………………..…. (d/m/y/). Work closed and Isolation removed.
Declared by Applicant Name…………………..…………… Date/Time………………………….…… Signature…………………….
Verified by Permit issuer………………………………………. Date/Time……………………………….. Signature………………………

Reviewed by Permit Approver………………………………. Date/Time……………………………….. Signature……………………..