ENGINEERING, PROCUREMENT, CONSTRUCTION AND

COMMISSIONING (EPCC) OF A WASTE TO ENERGY (WTE) FACILITY AT

THE JERAM SANITARY LANDFILL, KUALA SELANGOR, MALAYSIA

WORKING AT HEIGHT – PERMIT TO WOK

PART 1: PROJECT INFORMATION
Project owner: Department / Team / Tenant / Sponsor
Work location
Pemilik projek: (Lokasi kerja):
Name Name
SATSSB Spvsr. Nama: Contractor Spvsr. Nama:
Penyelia SATSSB Penyelia Kontktor.
No. Tel.: No. Tel.:
Contractor’s
Contractor’s Company Name
(Nama Syarikat Kontraktor)
Address
Alamat Kontraktor
☐ Lifting work (Kerja ☐ Confine space (Ruang
☐ Work at height (Kerja tinggi) ☐ Hot work (Kerja panas)
mengangkat) terkurung)
Type of work ☐ Work on roof (Kerja atas ☐ Work alone (Kerja ☐ Work at sensitive area (Kerja ☐ Cold work (Kerja
Jenis kerja:
bumbung) terpencil) di tempat sensitive) sejuk)
HSE hazardous work guideline being attached (Garispanduan kerja HSE disertakan)? ☐ Yes (Ya) ☐ No (Tidak)
Work activity /
process:
Aktiviti/proses kerja:
PART 2: REQUIREMENTS
☐ Electrical lockout/tagout ☐ Mechanical lockout/tagout ☐ Confined space entry
Work requirement: (Kunci/penanda elektrik) (Kunci/penanda jentera) (Pintu masuk ruang terkurung)
Keperluan kerja: ☐ Fall arrest ☐ Barricade /Hoarding ☐ Other
(Penahan kejatuhan) (Pagar / penghadang) (Lain-lain):
☐ Hand glove ☐ Safety helmet ☐ Goggle ☐ Face shield
(Sarung tangan) (Topi keselamatan) (Gogel) (Pelindung muka)
Type: Type: Type: Type:
☐ Body harness ☐ Safety shoes (Kasut ☐ Mask / Respirator ☐ Hi-visibility vest
(Abah-abah) keselamatan) (Topeng/ bantu nafas) (Ves pemantul cahaya)
Protective Type: Type: Type: ……………… Type:
Equipment:
☐ Ear Protection ☐ Safety Net ☐ Rain suit ☐ Safety cloth
Alat perlindungan diri:
(Pelindung telinga) (Jaring keselamatan) (Baju hujan) (Pakaian keselamatan)
Muff / Plug Type: Type: Type:
☐ Welding apron / suit ☐ Rubber mat ☐ Lightning detector ☐ Other (Lain-lain):
(Apron/baju kimpalan) (Alas getah) (Pengesan petir)
Type: Type: Type: …………………..
☐ Competent welder ☐ Crane operator
☐ Charge-man
(Pengimpal bertauliah) (Pengendali kren)
Competency ☐ Forklift operator ☐ Authorized gas tester ☐ Fire watch
requirement: (Pengendali trak angsun) (Penguji gas bertauliah) (Pengawal api)
Kemahiran yang ☐ Excavator ☐ Metal cutter/scrubber ☐ Air Tower Controler
diperlukan: (Penggali tanah) (Pemotong/gahar besi) (Menara kawalan udara)
☐ Signal man ☐ Scaffolding erector ☐ Other (Lain-lain):
(Tukang isyarat) (Pemasang perancah) ………………….
Isolation ☐ Domestic Water ☐ Electrical ☐ Telecommunication ☐ Road/ pathway
(Pengasingan) (Air domestic) (Bekalan elektrik) (Telekomunikasi) (Jalan/laluan)
Additional requirements / remarks (Keperluan tambahan) Chemical/oil declaration (Pengisytiharan bahan kimia/minyak)
Trade name Vol. Trade name Vol.

PART 3: PERMIT ATTACHEMENT

☐ Site evacuation plan (Pelan pengunsian tapak)
☐ Safety Briefing Acknowledgement (Perakuan penerangan keselamatan)
☐ Incident reporting form (Borang laporan kejadian)
☐ SATSSB PPE matrix (Matrik PPE SATSS)
☐ Excavation safety guideline (Keselamatan penggalian)
PART 4: DECLARATION
Contractor Project Supervisor
☐ Hot work permit (Keselamatan kerja panas)
☐ Construction safety guideline (Panduan keselamatan pembinaan)
☐ Work at height guideline (Panduan kerja di tempat tinggi)
☐ Lifting work safety guideline (Panduan keselamatan kerja
menggangkat)
Signature

I hereby confirm that all measures as specified above, in PART 5 and all instruction stated
in this work permit will be followed. Intolerable risk subjected to any violation of this Name (Nama)
permit’s requirement may cause work process being stopped. Position
(Jawatan)
PART 5: PERMIT EXPIRY
Date (Tarikh) d d m m y y Date (Tarikh) d d m m y y
From (Dari) Until (Hingga)
Time (Masa)
h h m m Time (Masa) h h m m
PART 6: PERMIT APPROVAL (PENGESAHAN PERMIT)
Health Safety & Environment Facility Management Work Location Manager
This permit is: ☐ Approved ☐ Not approved This permit is: ☐ Approved ☐ Not approved This permit is: ☐ Approved ☐ Not approved

signature/remarks signature/remarks signature/remarks

Name Name Name

Position Position Position
Date Date Date
SEC/HSE/REV.00.022