Jemena Asset Management
Permit To Work
Project:
Project No.:
Site Location:
A
DETAILS
 Confined Space
Service Order No.:
Permit Date:
Scope of Work:
B
 Excavation
 Hot Works
 Cold Works
Permit To Work No.:
Permit Open Time:
Permit Close Time:
RISK ASSESSMENT (confined space only)
Item
No.
C
Hazard and Risk
WORK CREW SIGN ON/SIGN OFF (confined space only)
Name
D
Risk Control Measure/s
Company
Date
Time In
Time Out
Signature
STAND BY AND RESCUE (confined space only)
Name
Document No.:
Template No.:
IDDP-10-002
12-001-2
Signature
Template Revision No.:
Template Revision Date:
2
21 Oct 2008
1 of 2
E







F
PERSONAL PROTECTIVE EQUIPMENT
Air hood
Air purifying mask
Chemical suit
Communications
Ear plugs/muffs
Fire extinguisher
First aid kit







Gas detector
Gloves
Hard hat
High visibility vest
Motion detector
Lifeline
Lifting gear
 Barricades
 Emergency procedures
Is isolation for the works required?
Facility valve/s
 Gas
Pipeline valve/s
 Water
Electrical/instrumentation
 Sewer
Isolation points (lock/tag out):
Tag No.
Time Isolated
Time Reinstated
1.
:
:
2.
:
:
3.
:
:
 Telecommunications
 Electricity
 Other
Tag No.
4.
5.
6.
ATMOSPHERIC TESTING
Is atmospheric testing for the works required?
Time taken
H2S (ppm)
Explosive (% lel)
:
:
:
:
:
J
EQUIPMENT
K
REFERENCED DOCUMENTS
Document No.
K
Time Isolated
:
:
:
Time Reinstated
:
:
:
VENTILATION
Is ventilation adequate?
I
 Warning signs
 Other
ISOLATIONS




H
Overalls/coveralls
Respirator equipment
SCBA
Safety glasses/goggles
Safety boots
Safety harness
Other
OTHER SAFETY PRECAUTIONS
 All personnel briefed
 All personnel trained
G







Rev
 YES
 NO
 YES
 NO
CO (ppm)
O2 (ppm)
Title
AUTHORISATION
All safety and environmental safeguards have been identified and are in place.
Permit Issuing Officer:
Signature:
Time:
L
SIGN-OFF
Permit Issuing Officer:
Signature:
Date:
Document No.:
Template No.:
IDDP-10-002
12-001-2
Time:
Template Revision No.:
Template Revision Date:
2
21 Oct 2008
2 of 2