Safe work permit Hot work permit Isolation or Lock Out/Tag Out permit New work Continuation of work Part 1: To be filled in by person requesting the Permit to Work Name of person requesting permit Work area Equipment to be worked on (unit no.) Work environment (check as applicable): Over water/unprotected Contaminated atmosphere Explosive atmosphere Safety systems disabled Confined space Other (specify) Nature of work to be performed (check as applicable): Working on safety systems Repairs Maintenance/Inspection Electrical work Hot work Routine work on hazardous job Non-routine work, no existing procedures Other (specify): Safety precautions required for work (check as applicable): PPE Equipment/Tools Hard hat Face shield Welding mask Fire detector Fire fighting equipment Gas/O2 analyzer SCBA Goggles Leather wear Blower/extractor Scaffolding Power tools Ear protection Rubber gloves/suit Safety line Arc welding Cutting/welding torch Grinder Safety harness Fall arrestor Work vest/lifejacket Crane Personnel basket Pressure gauge Survival suit Other (specify) Voltmeter/ammeter Rescue equipment Lock Out/Tag Out Other (specify): Safe operating procedures to be used Mech. Lock/Tag out* Pre-job safety meeting Client authorization Rescue team standby Watchman standby Clear area prior to start Elect. Lock/Tag out* Restricting access Installing barriers Grounding/bonding Clean,purge equip. Entry/vent locked open Tank filled with water Depressure equipment Protect fuel tanks Vapor/toxic gas test** Comb. gas test** Oxygen level test** Qualified electrician High voltage check Contractor orientation Lines carrying HAZMAT isolated Special procedures(specify what needed & attach procedure): * Give details of what is to be isloated or Locked/Tagged Out: ** See back of first copy for details of air quality monitoring requirements Names of persons performing the work: Was each of them briefed? (Yes/No) Part 2: Approval of Permit I authorize the work to start/continue provided working conditions remain the same. I have checked the safety devices. Validity: From (date): / / at: hr. min. To (date): / / at: hr. min. Name and signature of responsible person Part 3: To be signed only if work completed Part 4: To be signed if work suspended/not completed The work is completed during the validity, area & equipment restored Permit suspended at: / / at: hr. min. to safe operating condition. Removal of Lock Out/Tag Out approved. Work stopped, area is secured, isolation & lock out/tag out devices remain installed. Date: / / New permit is required to resume work. Date: / / Name and signature of responsible person Name and signature of responsible person Fig. 12.2 (cont'd) 10 Air quality monitoring requirements. Does the work require: Continuous monitoring Periodic monitoring at intervals Initial readings: Vapor/toxic gas tested for: Allowable exposure limit Safe working limits: * spark producing work: 0.0% combustible gas * tank/vessel entry: Oxygen between 19.5% and 21% * tank/vessel entry: combustible gas maximum 20% of LEL of that product * toxic gas limits: refer to MSDS Vapor/toxic gas test Combustible gas test Oxygen test reading time reading time reading time Subsequent readings (the following may be used to record additional air quality measurements): Vapor/toxic gas test Combustible gas test Oxygen test reading time reading time reading time