Revision: 00

Dated: Page 1 of 1
January 2016
LOCK OUT TAGOUT ORDER

Tag out Number: BOP-8-43 Date: 09-08-2017

1 Equipment Description Instrument air comp-3 Eqp. #

Code
Job Description Radiator Cleaning of instrument air compressor-3
Area TG hall JHA #

2 List all tags that are to be hung to achieve safety from the system. Continuation sheet used 

Tag # Description Eqp. # Lock # Tagged Position

1/2 CB of instrument air comp-3 OFF
2/2 Discharge Valve of compressor Close

Special Instructions:

3 Isolation (Print Name along with signature) Lock Box #

Switching order verified, Tags and
Date Time
Locks Hung by
4 Verification
By a person other than step-3 Date Time

Portable earth need to be installed Yes  No 

Location of Portable Earth

5 SM Approval & Authorization

Name: Signature: Date Time
Hot Work Permit Confined Space Permit EHWP #
# #

6 Craft Acceptance & acknowledgement of JHA (If Applicable) Print name along with signature

TAGOUT Temporary Tagout Release

Accept Release Request Release
(Portable Earth Installed if any) (Portable Earth Installed if (Portable Earth Installed if
any) any)
Name / Date / Time Name / Date / Time Name / Date / Time Name / Date / Time
Signature Signature Signature Signature

House Keeping Performed by Craft Person Name Signature

House Keeping Ensured by Area Engineer Name Signature

 If No Please Comment:
Is the JHA for the activity appropriate? Yes  No

7 Completion (Print name along with signature)

Removal of portable earth / ground
wires is verified and tags / locks Date Time
removed by

Equipment Restored for operational use

Date Time
SM Name And Signature