LOCK-OUT AND TAG-OUT

This permit must be displayed prominently at the work area

This permit is valid from (a.m/p.m) to (a.m/p.m) on day of issued

SECTION A - WORK REQUEST

Contractor: Expected Duration of Work:
Location: Date: Time:
Specific Work Area:
Equipment to be worked on:
Description of work:
Equipment Tag No.: (if applicable)
JSA No: N/A

SECTION B - CHECKLIST YES N/A SECTION C: AUTHORIZATION

1 Have multiply shifts required?
Have electrical power sources been identified,
2 disconnected with appropriate locks and tags applied,
and tested?
3 Do all disconnects have the capability of being locked
out?
Are there circumstances in the course of the job
4 where it is absolutely necessary to energize the
machine with their guards removed?
If yes to 3, have special instructions been provided to
5 do this job safely and controlling access to other
persons?
Are there circumstances in the course of this job for
6 electricians to troubleshoot energized electrical
apparatus?
If yes to 5, have special instructions been provided to
7 do this job safely and controlling access to other
persons?
8 Protective equipment to be used:
Rubber boots Hard Hat
Gloves Face Shields
Safety Shoes Safety Glasses
9 Additional Precautions to be taken:
10 Permissionics hereby given to the bearer of this permit to
carry out the above mentioned work under the provisions
stipulated iun this permit and in accordance with the Work
Permit System
Signature by: Contractor Site Managers
SECTION D: AUTHORIZATION
11 Permissionics hereby given to the bearer of this permit to
carry out the above mentioned work under the provisions
stipulated iun this permit and in accordance with the Work
Permit System
Safety harness
Hearing protection
Signature of Haskoning' representative
SECTION E: ACCEPTANCE
12 I understand the scrop of work to be done and safety
precaution to be taken. I agree and accept all the
provisions procedures and shall cease work should
condition affecting safety aspect of the work changes

Signature by: Authorized Contractor Supervisor

SECTION F: CLOSE OUT
13 Completion/Cancellation
I certified that the above mentioned work has been completed
has not commenced
(Tick as appropriate) has commenced but is not complete

Signed: Name: Time: Date:

(Performing Authority)
I declare that this permit is now withdrawn and cancelled.

Signed: Name: Time: Date:

(Approving Authority)

1st copy: Post At Job Site 2nd copy: keep to file 3rd copy: to HSE