EX03 - PERMIT TO WORK (COLD POTENTIAL)

section 1 : inspection, installation & test

date : 11 Desember 2021 bay : Ruangan peserta?

start time : 08.00 expired time : 11.00
performing authory Nama Peserta ?
task description/carry out safe isolation on LV lighting circuit in the comp-EX workshop
RA number gas free certification number
hazard low voltage working at hight flammable gases adverse weather
l, area authority, declare that all hazards have been identified and all specified control measures are in palce and it is now safe for the work
specified on section 2 of the permit to performed

Print : Assessor .......... signed : .......... time : 08.00..........

l, performing authority, have read and understood the above conditions and precautions, i accept responsibillity for crraying out work
as specified. I will notify the area authority on completion or interruption of this work

Print : Peserta.......... signed : .......... time : 08.00 ..........

Cancellation
l, performing authority, declare that work for which this permite was issued has been properly performed, and that the equipment, plan and
electrical apparature by the work have been left in safe, celar condition
the work is complete the work is incomplete

Print : Peserta.......... signed : .......... time : 10.50 ..........

l, area authority, have inspected the equipment/work area anf declare test that work for which this permite wa issued has been properly
performed, that all tools and apparatus hav been removed, and that equipment apparatus effected by work have been left in save clean condition

the work is complete the work is incomplete

Print : Nama Assessor.......... signed : .......... time : 10.50..........

comp-EX EX03 competance validation test

candidate name : date :

visual inspecton report

item sutable comments and observations glands

BB 1 OK OK

JB 1 OK Special Condition Apply OK

JB 2 OK Special Condition Apply OK

FD 1 OK Special Condition Apply To be Install

FD 2 Not OK Equipment not follow datasheet OK

schedule of test result

test equipment
make model serial No. calibrated

Fluke Cek Actual Cek Actual Yes

conductor size insullation resistance

circuit
point to point test voltage 1000VDC
discription core screen
core - core - core - screen -
core screeen earth earth
IS, LED lamp 1.5 0.75 0.2 >2.2G ohm >2.2G ohm >2.2G ohm >2.2G ohm
IS, smoke detector 1.5 0.75 0.2 >2.2G ohm >2.2G ohm >2.2G ohm >2.2G ohm