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AHB

PASSION
FUELS
PERFORMANCE

GREATSHIP (INDIA) LIMITED


ISOLATION CERTIFICATE

Rig Name:
1.0

Isolation Certificate No.:

REQUEST FOR ISOLATION PERMIT (PERSON CARRYING OUT WORK)

Person Carrying out the Work: _____________________________________________________________________________


_________________
__________________
Brief Description of task: __________________________________________________________________________________
_________________
_________________
Location: ______________________________________________________________________________________________
_________________
olation: _______________________________
___________
_________________
Starting Time: ______________________ Date: ____________ Estimated De-Isolation:
_________________
_________________
Equipment to be Isolated : ________________________________________________________________________________
2.0

ISOLATION PROCEDURE (COMPETENT PERSON)

2.1

ELECTRICAL ISOLATION
Location

2.2

Equipment

Action Taken

Breaker #

Fuse Withdrawn

Tagged Out

Lock #

Open

Locked

Yes

No

Yes

No

Open

Locked

Yes

No

Yes

No

Open

Locked

Yes

No

Yes

No

MECHANICAL / OTHER TYPE ISOLATION

Location / Line / Valve

Stored Energy Bled Off

Control Mechanism

Lock #

Tagged Out

Valves Closed

Yes

No

Yes

No

Yes

No

Lines Blanked

Open

Closed

Yes

No

Yes

No

Any

Yes

No

Yes

No

Yes

No

Precautions Taken:
pment have been proven
p
I hereby confirm the above Isolations and Equipment
de-energised.
Name of Competent Person: _____________________ Signed: ________________ Time: ____________ Date: ___________
3.0

RESPONSIBLE PERSON AUTHORISING WORK ON EQUIPMENT

Name: _____________________________ Sign: __________________ Date: _________________ Time: ________________


4.0

ACKNOWLEDGEMENT OF ISOLATION BY PERSON IN CHARGE OF WORK

I acknowledge Receipt of a copy of this Isolation


olation Certificate and understand
u
that the equipment has been Isolated and is safe to work on.

a. Person in Charge of Work: _________________


_______________ Signed: ________________ Time: _______________ Date: ____________
b. Person in Charge of Work: _________________
_______________ Signed: ________________ Time: _______________ Date: ____________
If work is continuing afterr shift change, Isolation must
m
be referenced in shift handover to relief.
5.0

COMPLETION OF WORK

I hereby confirm that


abo is complete and Isolation may now be removed by a Competent Person.
hat the work detailed in sec 1 above
Signed: _____________________
in Charge of Work: _______________ Time: ______________ Date: ____________
_______________ Person
P
6.0

CONFIRMATION OF DE-ISOLATION

I herebyy confirm that


hat the work detailed in sec 2 has been removed and the system is De-Isolated.
Signed:: _____________________
Person in Charge of Work: _______________ Time: ______________ Date: ____________
_____________
7.0

LONG TERM ISOLATION

I herebyy confirm that the work detailed in Sec 1 above is not complete and the equipment has been entered as Long Term Isolation.
Signed:: _____________________ Person in Charge of Work: _______________ Time: ______________ Date: ____________
Verified by: __________________ Competent Person: _____________________ Time: ______________ Date: ____________
ARCO-GIL-P-04-HSE-IC