Appendix 7a)

PUBLIC UTILITIES BOARD

LOCKOUT / TAG OUT (LOTO) PERMIT
Location Of Work: _______________________

PTW No:__________

Description of Work :
Commencement

Date :____________ / Time : ____________

Target Completion

Date : ______________

S/N

Equipment

Tag No

Action

LOTO ()

LOTO (x)

Remarks

1
2
3
4
5

Apply : I have checked for the conditions stated above and ensured compliance.

____________________________
Name of Supervisor / Company

____________________
Signature & Date

Approve : I have verified the compliance with checklist mentioned above and approval is given
for work to commence.
*(Competent person certificate verified (if any) )

_____________________________
Name of PUB Supervisor

____________________
Signature & Date

_____________________________
Name of Approving Officer

____________________
Signature & Date

Appendix 7a)
Completion / Cancellation : I have verified the work completion and safe removal of LOTO
Cancelled by Supervisor :

Verified by PUB Officer :

_____________________________
Name / Sign / Date

__________________________
Name / Sign / Date

Lockout/Tag out Procedures

The following lockout / tag out procedures must be followed during servicing and/or
maintenance of system / equipment.
1. The authorized persons will make themselves aware of the energy types associated
with the equipment to be locked out.
2. Notify all affected employees that lockout / tag out procedures are about to occur and
which equipment will be affected.
3. Shut down the equipment using normal stopping or shut down procedures.
4. Isolate the equipment from all its energy sources.
5. Apply appropriate lockout / tag out devices to the equipment's energy isolating
devices.
6. Release all potentially hazardous stored or residual energy
7. Verify that the equipment cannot be started.
Removal of Lockout/Tag out
The following procedures must be followed for the removal of the lockout / tag out devices
1. Replace all shields and guards and ensure that all equipment components are intact.
Clear the tools and materials.
2. Move employees away from hazardous areas;
3. Notify affected employees that the lockout / tag out devices are going to be removed
and that the equipment is going to be re-energized.
4. Make sure that all switches, valves and energy controls are in the "off" or "safe"
position.
5. Remove the lockout / tag out devices.
6. Test the equipment to ensure that it is operating properly.