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PERMIT AUTHORITY

VALID FOR 7 CONSECUTIVE 0,

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I herebyd~egateauthor~ytothePerm~C

precautionsand prescribed isolationsare

~~~~~~~....::..L-  --- -- -- -~~~~~~~~~~~~~~~~~~

can proceed.

Equipment/tools: : rr t?

ZCi ZJt P /

O J~~ t

Designation:

 ¥

Signature:

7

ASSOCIATED PERMITS

CERTIF

Daily Permit endorsements by Permit Applicant

YES0

PERMIT No.

No .-----/

I--------t-----i-

LtLJ

CERTIFICATES Certificate Certi

ElectricalWork

Name: 6~·Y Ctc. Designation ~~Sign: ~

~ ~   = = = = = = = = =   ~   =   ~ ~   = = = =   =   = = = = = = = = = = = = =   l

xcavation

2. AREA CLASSIFICATION By Permi t Authori

~~~~~~~~~~->--'<--~~~~~- -''--~~-,--~~~~~~~--f Prepare / Reinstate

D Hazardous: D Zone 0 D Zone 1 D Zone 2 [iZINon Hazardous

I--~~~~~~~- -~~~I----;

Confined Space Entry

HAZARDS IDENTIFICATION

B

Permit Authori YES

  ]

NO [R]

Other

Liquid / gas under pressure [XJ Heat/cold 0

8. INITIAL GAS TEST By Authori sel

Flammable gas / liquids CZI Oxygen deficient (confined space) [R]

rv 1

The following readings were checked

~ Excavation/boring I  I

~~~~~~~~~~~~~~~1-~~~~~-'-~~~~~~~~Date:. __ ~~~~~~~~~~_

Toxic material

[C]

Electrical Hazard ~

  ~ t~~~ ~~ ~~ _t Oxygen(%),:.-· LEL(%): _

Pyrophorics [4J Blasting (dust) ~

~~~~~~~~~~~~~~~;-~~~~~~~~~~~~~--fName:

Moving machinery

0

Falling hazard

W --~~~~~~~~~-

Portable gas detectors required at wor

Adjacent operations/Live plant c : z J Falling Objects

C8J

9. PERMIT CONTROLLER DECLARJ 

Naked flames or arcs

[Xl

Heavy lifting/rigging

[XJ

-~~~~~~~~~~~~~-- ---~~~-----~-:--~-I

1.

1/

my appointed delegatehave insped

Use of equipment generating sparks ~ High Noise [2g

~~~~- --- - -~- -= ---~~-- - -- -- --~-~~~--~~~~~

  I am aware that this work is being earn

Other Hazards: specified inthis permitare under my n

~

Corrosive materials

4. SITE PREPARATION B Permit Authorit

YES Ivl

NO

Process / positive isolation

[:cJ

N2 purging

Electrical isolation

~ Ventilation (natural/forced)

Safety taq/lock

Discarded materials kept wet

W

Other:

Name:~~-~~~~~~-~

PERMIT APPLICANT

10. PERMIT APPLICANT

WORKSI-r

5. PROTECTIVEMEASURES

SAFETY EQUiPMENT By PC) YES I

v

NO [R]

Coveralls / Boots / Hard Hat

0

Banks man

0

Name: G  4

t:Lc

-E-y-e-/W-e-Id-e-rgo-g-g-Ie-s-----------O--- --F-ul-I/-p-a-rt-ia-I-ch-e-m-j-ca-I-s-ui-t  0  1Designati~ur1~ ff No.~8/

Safety barriers / signs /Habitat

0

PVC gauntlets/Gloves

0

Sign:--~-~-::::o-.....,..~~~~~-

_E_S_D~/_F_&_G_o_v_e_rr_~_e_s_o_n~~~~_~~~~D_r_a_in_s_s_e_a_~_d_w_i_fu_in~50_·_r_ad_i_u_S_~~~~1.~worka~pre~~o~~ ~~~~

czj

Area clear of flammables [X out under my overall responsibility.

r ;:;7 1

f'V 2.

The WorksiteSupervisor under my

Depressurisation ~ Gas testing ~ supervision has beenfully briefed and

Equipment Drainin 0 Equipment Earthling 5(] understandsthe Permitto Work / Site

Safety Rules.

Water / steam flushing [E] Scaffolding certified 00

Hearing protection 0 Dust mask 0

TRANSFER OF RESPONSIBILITIES

~~~~~~~~~~~~~_O~---l_F_ir~e_E~X~ti~n~gu~i~sh~e~r~~~~~~I==~1---lName: __ ~~~~~~~~~_

oPressurized fire hose

0

Safety harness / Inertia reel

0

Fire Blanket

0

Designation: --- Staff No.: --

-P-e-rs-o-n-a-I~a-s-M-o-n-it-o-r~~~~-O~---l-A-d-d-it-io-n-a-II-jg-h-ti-ng~~~~~-O~~-l Sign: --~~~~~~~~~~_

D

Disposable Coveralls

0

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r, who shall ensure that all the required

and the worksite is safe before the work

Date:

Time:

Oxygen

SHIFT 2

H2S (ppm)

LEL

(By Permit Controller)

------------------i

In itia ls:

r   ~~ ~  ~ ~ ~

SHIFT 3

-'-----'----- ---......-----i

ate:

Tester)

1--------1----+---+----1-----1----+---1----

---....:---------------------l

T ime:

worksite: r t  t  t  t  f  t 

Oxygen

im e ( ,h ,rs:;..L)  :  : _

H2S (ppm )

: _

YES D NO D

H 2S (ppm ): -- -------- LEL

Initials:

Date:

12. PERMIT APPLICANT ENDORSEMENTS (Initial)

OF WORKSITe PREPARATION

worksite.

t and that the precautions

I

isolations

ility.

n: _

TRANSFER OF RESPONSIBILITIES

ame: _

:

  ~ 

Initials:

13. SHIFT CHANGE ENDORSEMENTS (Initial)

Dat e: