FORMULIR

IZIN KERJA / PERMIT TO WORK

A. POTENSI BAHAYA / POTENTIAL HAZARD Permit No : PTW-RIM-RBM-RSS-2023-015739

1. Ergonomi
2. Bekerja Ketinggian Tangga
3. Housekeeping
4. Peralatan Berputar / Rotating Equipment
5. Biologis / Biological
6. Benda Bergerak / Motion
7. Mekanis Perkakas Tangan
8. Listrik
9. Kebisingan / Noise
10. Pengangkatan Manual/Manual Handling
11. Suhu / Temperature
12. Debu
13. Bekerja Ketinggian Perancah
14. Kerja Panas/Hot Work
15. Bahan Berbahaya & Beracun (B3) / Hazardous Material
16. Gravitasi / Gravity

Lokasi RSS Taman Sambas Area Spesifik Lainnya

Pemohon Febrian Sabda Ramadhan Jabatan - Perusahaan Deputy Project Manager

JENIS PERALATAN
B. DESKRIPSI KERJA /WORK DESCRIPTION
/TYPE OF EQUIPMENT

Deskripsi Pekerjaan 1. Toolbox meeting 2. [Predictive] water supply system – pengecekan level air tangki
3. [Predictive] Pengecekan suhu, vibrasi, Noise pompa booster atau pompa transfer 4. [Preventive] water
supply system- cleaning pompa booster atau pompa transfer 5. [Preventive] Water Supply System - Cleaning
Pompa Booster atau Pompa Tranfer 6. [Preventive] Water Supply System - Cleaning Strainer Pompa Booster
atau Pompa Tranfer 7. [Preventive] Water Supply System - Pengetesan Fungsi Pompa Booster atau Pompa
Tranfer setelah preventive 8. [Corrective -Pembongkaran Pompa] Water Supply System - Cutt Off Listrik dan
valve pompa 9. [Predictive] Sanitary Drainage System 10. [PREDICTIVE] (Pedestrian pump dan semua aksesoris
pendukung) pengecekan tes fungsi, beban arus, tegangan arus listrik , pressure gauge, kebocroan, suhu,
noise , sumersible pump 11. [PREVENTIVE] (Sanitary Drainage System)Cleaning bagian luar pompa 12.
[PREVENTIVE] (Sanitary Drainage System) Pengetesan pompa Booster atau pompa transfer setelah preventive
13. [CORRECTIF] (Pembongkaran Pompa) Cut off Listrik dan valve pompa 1 14. [Predictive] Fire Pump System -
Pengecekan Kondisi fire pump 15. [PREDICTIVE] - Pengecekan nilai pressure pada panel dan pressure gauge,
kebocoran (Seal, gland, pipa, fitting, valve) Parameter, Suhu, vibrasi, Noise, beban arus dan tegangan 16. 1. Alat
[Preventive] Fire Pump System - Cleaning Fire Pump 17. [PREVENTIVE] - Fire Pump System - Cleaning Strainer Pelindung
18. [PREVENTIVE] -Fire Pump System - Pengetesan Fungsi fire Pump setelah Preventive 19. [Corrective]- Diri
Pembongkaran Pompa (Fire Pump System)- Cutt off listrik dan valve pompa 20. [Predictive] - Pengecekan 2. Alat
Ventilation FAN system 21. [Predictive] - Pengecekan suhu, vibrasi, noise, beban arus dan tengangan arus Keselamatan
FAN 22. [PREVENTIVE] Cleaning Blade fan 23. [PREVENTIVE] – Pengetesan fungsi fan system setelah preventive 3. Peralatan
24. [Correctif] – Ventilation Fan System – Cutt off listrik 25. [PREDICTIVE] – Pengecekan tunnel fan Tangan /
system 26. [PREDICTIVE] – Tunnel fan System-Pengecekan suhu, vibrasi,noise,beban arus dan tegangan arus Hand Tools
27. [PREVENTIVE] Tunnel Fan System - Cleaning Blade fan 28. [PREVENTIVE] – Pengetesan fungsi tunnel fan 4. Mesin /
system setelah preventive 29. [Correctif] – Tunnel Fan System – Cutt off listrik 30. [PREVENTIVE] Machine
Electrical SystemCleaning UPS 31. [Corrective]-Pembongkaran Panel (Electrical System) 32. [Predictive] -
Electrical Lightening System - pengecekan terminal Box dan nilai grounding 33. [Correctif] - Electrical
Lightening System - Pelepasan kabel grounding 34. [Predictive] - Lightening Protection System- pengecekan
terminal Box dan nilai grounding 35. [Predictive] - Grounding Systempengecekan Grounding dan busbar 36.
[Corrective] - Grounding System - Pelepasan kabel grounding 37. [Corrective] - Perbaikan Pipa Floor Drain
38. [Predictive] - Passenger Information Display Systempengecekan Passanger Information Display 39.
[PREVENTIVE] Passanger Information Display- Cleaning PIDS dan Re-thegtening 40. [Predictive] - Building
Automation System- pengecekan komputer BAS 41. [Predictive] - Public Addres System- pengecekan Speaker All
station dan building (Amplifier TOA) 42. [Predictive] - Public Addres System- Cleaning & Re-tegthening
Amplifier 43. Thermal Scan System- Cleaning & Re-tegthening Thermal Scan 44. [Predictive] – Pengecekan
Power Supply DINA, Bike Conveyor, Sensor Tangga, Signage, Hoist Crane dan semua komponen pada Other System
45. [Correctif] -Power Supply DINA, Bike Conveyor, Sensor Tangga, Signage, Hoist Crane dan semua komponen
pada Other Systempembongkaran 46. Housekeeping

C. DOKUMEN YANG DIBUTUHKAN / REQUIRED DOCUMENTS

Work Order & Job Safety Gambar / Drawing. ( Upload Form Lain-
Instruction Analysis ) Pemeriksaan lain/Others

Catatan:
-

D. TINDAKAN PENCEGAHAN YANG DILAKUKAN / TYPE OF CONTROL

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 Eliminasi / Elimination Substitusi / Substitution Engineering

Administrasi / Administration APD/PPE

Catatan:
-

E. PERNYATAAN PERSETUJUAN / APPROVAL STATEMENT

Setuju Tidak
Penyataan / Statement / Setuju /
Agree Disagree

Saya tidak boleh membuat kerusakan peralatan di area kerja / I must not make damage to the any equipment in
the work area

Saya tidak akan menimbulkan debu dan memperhatikan kebersihan lingkungan selama dan setelah pekerjaan./ I
shall not make dust and pay attention to clean of enviroment during and after work.

Saya tidak akan menimbulkan suhu lebih dari 25 derajat dalam STER /SCR / I shall not generate heat more
than 25 degree in STER/SCR.

Jika terjadi suatu gangguan, saya informasikan ke Area Authority dengan segera / If something trouble
happnen, I shall inform Area Authority immidiately.

Setelah saya merubah peralatan, level atau lainnya, akan saya sampaikan dan mutakhirkan data yang
diperlukan dengan segera jika ( mis: hasil test, data dan as-built ) / After I change the equipment, level
or something, I shall submit and update the necessary data (ex. test result, data and as-built) immidiately

Jika saya menyambungkan PC ke peralatan, saya harus menjamin keamana perangkat lunaknya / When I use PC to
connect equipment, I shall take care Software

Jika Otoritas Area atau OCC memerintahkan untuk menghentikan kegiatan, saya akan mengikuti perintah / When
Area Authority or OCC command to stop the work, I shall follow the command.

Apabila waktu bekerja saya sudah habis maka area kerja harus dalam kondisi rapih dan bersih serta sisa
pekerjaan, bila ada, tidak menggangu aktifitas disekitarnya. / If my working time has run out therefore
working area have to be in neat and cleand condition also remaining works , if any, not impact to
surrounding activity.

Saya akan memastikan keselamatan rekan kerja serta orang lain di sekitar saya / I will makesure the safety
of all work team members and others peoples around me

Saya menyadari bahwa saya berhak dan akan menghentikan pekerjaan segera jika terdapat sesuatu yang tidak
aman dan berpotensi mengakibatkan kecelakaan / I am aware that I have authority to stop the job immediately
if there's something that potential to lead to an incident

F. DAFTAR PEKERJA / LIST OF WORKERS

Nama Posisi Perusahaan

Heri Teknisi PT YES

Dimas Teknisi PT YES

Irfan Leader PT YES

Dika Adi Priyanto Teknisi PT YES

Fajar Cahyadin Teknisi PT YES

Andika dewanto Teknisi PT YES

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 Willy Christoper Teknisi PT YES

Amril Teknisi PT YES

mubonur Teknisi Teknisi

Adi satrio Teknisi PT YES

fikri Teknisi PT YES

ade Teknisi PT YES

panji Teknisi PT YES

malik Teknisi PT YES

dimas rizky Teknisi PT YES

G. PENGAJUAN IZIN KERJA / PERMIT SUBMISSION

Saya menyatakan bahwa Saya telah membaca & memahami K3 & pekerjaan ini akan dilaksanakan sesuai dengan segala persyaratan yang
ada / I delclare that I understand the safety procedure regarding this jobs

Specialist/Engineer/Technician Tanggal Approval Jumlah Pekerja

M Irfan Julkarnaen ( General Equipment Maintenance Underground Technician ) 31-05-2023 15

H. PENGELUARAN IZIN KERJA/ PERMIT ISSUANCE

Izin diberikan untuk kerja dijalankan yang tertera diatas selama / Permit is given as proposed scope above

Pemberi Izin Permit Approver (Ka. Seksi/Ka. Dept) Tanggal Approval

Wira Vireza ( General Equipment Maintenance Section Head ) 31-05-2023

I. AREA AUTHORITY

Izin memasuki area kerja diberikan selama/Permission to enter the work area is given during

Jangka Waktu PTW Area Authority Additional Area Authority

Dari : 30-05-2023 Timothy Oliver Octavianus ( Power Maintenance Section Head ) ( )

J. REVALIDASI PERMIT

Pengisian kolom ini dilakukan jika terjadi perubahan kegiatan & perubahan/penggantian hari

Hari Approval Pengajuan Izin Kerja Approval Area Authority

Hari 1 NOT APPROVED NOT APPROVED

Hari 2 NOT APPROVED NOT APPROVED

Hari 3 NOT APPROVED NOT APPROVED

Hari 4 NOT APPROVED NOT APPROVED

Hari 5 NOT APPROVED NOT APPROVED

Hari 6 NOT APPROVED NOT APPROVED

K. AKHIR PEKERJAAN

Saya menyatakan bahwa pekerjaan telah selesai dan telah dilakukan pengecekan lokasi pekerjaan

Pengajuan Izin Kerja NOT APPROVED

Keterangan :
Pemberi Izin NOT APPROVED

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