SERTIFIKAT BAHAN MUDAH
TERBAKAR/ FLAMMABLE
CERTIFICATE
Appendix-5
1.
2.
Identitas pekerjaan/ Identity of Work
(1) Lokasi Pekerjaan/ Work Location
(2) Jenis Pekerjaan/ Type of Work
(3) Uraian Pekerjaan/ Description of Work
(4) Nomor Izin Kerja/ Permit Number
(5) Nomor Sertifikat/ Certificate Number
:
:
:
:
:
Check List Keselamatan/ Safety Check List
Item
2.1 Lampiran JSA/
Appendix of JSA
2.2 Bahan bahan mudah terbakar sudah disingkirkan (drain,
flushing, purging)/
Flammable materials have been removed (drain, flushing,
purging)
Y/N
N/A
Remark
Tanggal :
Pukul :
Hasil :
Oleh :
2.3 Pengetesan gas explosive sudah dilaksanakan/
Gas explosive testing has been carried out
2.4 Alat pemadam kebakaran telah tersedia/
Fire extinguisher is available
2.5 Proteksi percikan bunga api telah tersedia/
Protection of sparks is available
2.6 Semua peralatan untuk pekerjaan panas telah diinspeksi dan
aman digunakan/
All equipment for hot work has been inspected and is safe to
use
2.7 Perlengkapan pengelasan sudah ditempatkan dengan aman,
digrounding dan dilindungi dari busur api /
Welding equipment has been placed safely, grounded and
protected from arcs
2.8 Semua tabung gas bertekanan ditempatkan dengan aman dan
stabil/
All pressurized gas cylinders are placed safely and stably
2.9 Fuel gas & Oksigen dilengkapi dengan flashback arrestor/
Fuel gas & Oxygen are equipped with flashback arrestor
2.10 Stand by petugas pengamat api (jika diperlukan)/
Stand by fire observation officer (if needed)
2.11 Apakah diperlukan sertifikat ijin kerja yang lain?/
Do you need another work permit certificate?
Confined space entry
Working at height
Certificate Isolation energy
……………………………………
2.12 Akses masuk dan evakuasi dalam kondisi baik/
Access in and evacuation is in good condition
3.
Instruksi Tertulis/ Written Instructions
Instruksi khusus/ Special instructions:
……………………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
4.
Validitas Certificate/ Validation Certificate
Sertifikat ini berlaku 7 hari dan menjadi tidak valid jika/ This certificate is valid for 7 days and becomes invalid if:
(1) Pekerjaan selesai/ Work completed
(2) Pekerjaan disuspend/ Work suspended
(3) Terdapat bahaya baru yang belum dikendalikan/ There are new dangers that have not been controlled
5. Kategori/ Category :
Tidak Kritis/ Non Critical
Kritis/ Critical
Diterbitkan oleh :
Tanggal:
Diverifikasi oleh:
Tanggal:
Disc Superintendent
Pukul:
SHE Coord/Spt/Inspector
Pukul: