PSP PERMIT TO WORK FORM
Date of issue : 04-Feb-2025 No : 28
Terminal Site Location
PS Pipeline - Terminal 1 KVDT Test
Form Type Technician Description of work
KVDT TechPH Terminal1 test
From Until Risk level
04-Feb-2025 10-Feb-2025 Low
Appendix - Associated Certificate
Excavation
No Status Validity From Validity To
EXC001 Lead Permit Issuer Approved 04-Feb-2025 10-Feb-2025 Expired
Isolation
No Status Validity From Validity To
INT001 Engineer Acknowledge 04-Feb-2025 10-Feb-2025 Expired
MEC001 Engineer Acknowledge 04-Feb-2025 10-Feb-2025 Expired
ELE001 Engineer Acknowledge 04-Feb-2025 10-Feb-2025 Expired
Lifting and Hoisting
No Status Validity From Validity To
LIF001 Lead Permit Issuer Approved 04-Feb-2025 10-Feb-2025 Expired
Radiation
No Status Validity From Validity To
RAD001 Lead Permit Issuer Approved 03-Feb-2025 09-Feb-2025 Expired
PERMIT HOLDER
Name Company No.Of Staffs
Contract Staff Contracting Company true 0
Staff List
No data available.
CLASSIFIED AREA
Where With What
Zone 0- Product Tank, Interceptor, Confine Space. Explosion Proof/Intrinsically Safe
Zone 1- Loading Gantry, MPP Receiving, Tank Farm, Spark Free Tools
Additive Area, MPP Pump & Receiving Stations.
Lifting Equipment/Crane
Zone 2 - The rest of KVDT Terminal's Area and MPP
Scaffold
Block Valve Stations.
Other
UnClassified - Area Outside Terminal.
OPERATIONAL INFORMATION
Where
Opening Confined
Excavation High-pressure Jetting Electrical Activities
Space
Entering Confined
Welding Grit Blasting Nitrogen pressure test
Space
Assemble Working at Height X-ray/Radiography Hydrostatic test
Disassemble Cutting Prefabrication Drilling/Grinding
Calibration Other
PPE
Where
Safety Glasses Safety Harness Helmet Full Face Mask
Leather Gloves Fall Protection Ear Protection Breathing Protection
Safety Shoes Neoprene Gloves
ADDITIONAL PPE
PRODUCT INVOLVED WORKING AREA
Class Demarcation
Fire Extinguisher
Use of Warning Signs
Others
OPERATIONAL MEASURES
MECHANICAL ELECTRICAL INSTRUMENTATION
Equipment Instrument Equipment/Electrical Motor
(Specify)
ID/Tag Number ID/Tag Number
ID/Tag Number
SME SME
SME
Pressure free Locked off
Empty Isolated Locked off
Disconnected Remark Isolated
Blanked off Disconnected
Locked off Bypass
Flushed Remark
Ventilation, specify
Remark
Engineer
Engineering Advice Required
WORKING AREA
Permit Supervisor is aware of the safety instructions as in the:
Terminal safety manual
Permit to Work and associated certificates
Name Date And Time
TechPH Terminal1
Precautions for the work (in addition to those overleaf, and stated in associated certificates)
I certify that I have fully considered the implications of the work in line with the responsibilities detailed in the
permit to work procedure and that the above precautions are adequate for the work to be carried out provided
that the precautions are established and maintained.
Engineer Name Date/Time
Operation Manager Name Date/Time
Permit Authorized By
HSSE VERIFIER Permit Issuer(PI) LEAD PERMIT ISSUER (LPI)
Verified all the HSSE requirement Authorised for execution without Authorised for execution only in
in place including JMS and JSA additional certificates accordance with attached
HSSE Verifier Name PI Name certificate
LPI Name
Date/Time Date/Time
Date/Time
From
From
Until
Until
Operational Measures: To be signed by Operation Executive (for MPP) or Controller (for KVDT)
Shut down system operational
Fire protection system operational
Automatic fire protection system operational
Any Other Measure
Permit validity (where work is going to last more than the duration of a day)
Permit issuer & Permit Holder confirm by signing that the precautions required to work safely have been
complied with prior to starting work each day or work period. At the close of each day, the Permit Issuer & Permit
Holder sign to confirm that the area has been left in a safe condition (although it is still not an operational area,
i.e. it has been handed back) and that all staff have left the site.
PERMIT CLOSE OUT
PERMIT HOLDER PERMIT ISSUER / LEAD PERMIT ISSUER
Close Out – Work Completed Signing Off – Accepting completion of the
Name work
Name
Contract Staff
Date/Time
Date/Time
Remark
Remark
Excavation Certificate No : 28
DIGGING INSTRUCTIONS TO THE PERMIT APPLICANT
Piping and electrical/instruments must be localised by hand digging (with spades).
Identified cabling and piping must be marked with wooden pegs.
Piping and Cabling may have moved from its original location, as indicated on as-built drawings, due
to soil statement.
Within 1-meter radius around piping and cabling, only hand digging with spades may be used.
Excavations deeper than 1.2 meters require slopes of max. 70 degrees or side supporting structures
to prevent collapse.
Use of digging machinery is allowed: Yes/No (A Gas Test Certificate – Hot work is required).
Exposed piping and cabling to be supported.
Workers maintain safe distance while equipment is in operation.
Spoil pile must be at a minimum of 0.75 meters from the edge of the excavation.
Excavations 6 meters or deeper require the services of a specialized Engineer.
The handling of contaminated soil requires the use of PPE as defined on the Permit to Work.
Before/during excavation application, contractor MUST refer to the owner/specialist which familiar to
the specific site.(ROW and Land Exec).
Utilities mapping/ as built drawing/ excavation drawing MUST be attached with the certificate.
Pipeline exposure more than a day must be protected and surrounded by sandbag and guarded
overnight.
PSP REPRESENTATIVE ON SITE WHILE EXCAVATION IS IN PROGRESS
Name Location Date and Time
Contract Staff Test 04-Feb-2025
I have checked the site/studied the layout drawings and certify that the excavation proposed under Permit to Work
number 28 dated 04-Feb-2025 can be carried out:
a. Without risk of damage to any underground services
b. Provided that the following additional precautions are taken to prevent damages to the equipment/services
specified below:
test
Situation Sketch/Indication of Hazards
ePtw.jpg
Validity From Validity Until
04-Feb-2025 10-Feb-2025
Engineer LPI Excavation Certificate is certificate
and permit to work are withdrawn:
I certify that I have reviewed the Excavation Certificate is described Permit Holder Name
proposed work and I am satisfied in the permit to work is allowed
Contract Staff
that it is adequately described on between: Permit Holder Date/Time
the permit to work and that the
PI Name
precautions detailed are adequate
lpi Terminal1 Permit Holder Reason
and clearly defined
Name Date/Time
Engineer PSP Terminal1 17-Feb-2025 LPI Name
Date/Time lpi Terminal1
From
04-Feb-2025 04-Feb-2025 LPI Date/Time
Until
LPI Reason
10-Feb-2025
Isolation Certificate-Lock out/Tag out No : 28
(To be completed only by authorised persons)
Identify number(LOTO number) Isolated Equipment Location
3 3 Test
Operational Measure Types Validity From Validity Utill
Mechanical 04-Feb-2025 10-Feb-2025
PERSON(S) COMPLETING THE ISOLATION
Name
Isolation Owner IO- Terminal1
Isolation Verifier IV Terminal1
I have personally checked the equipment to be worked on under this Isolation certificate and certify it to have
been isolated. Accidental reconnection of this equipment has been prevented by the following means:
Electrical Mechanical
Engineer LPI Isolation Certificate is certificate
and permit to work are withdrawn:
I certify that I have reviewed the Isolation Certificate is described in Permit Holder Name
proposed work and I am satisfied the permit to work is allowed
Contract Staff
that it is adequately described on between:
the permit to work and that the Permit Holder Date/Time
PI Name
precautions detailed are adequate
and clearly defined
Date/Time Permit Holder Reason
Name
Engineer PSP Terminal1 From
Is This Deisolate?
Date/Time 04-Feb-2025
LPI Name
04-Feb-2025 Until
10-Feb-2025 LPI Date/Time
LPI Reason
I have personally checked the equipment isolated above and confirm that work on it is completed and said
equipment has been re-connected and is in a safe working condition.
Name
Isolation Owner IO- Terminal1
Isolation Verifier IV Terminal1
Isolation Certificate-Lock out/Tag out No : 28
(To be completed only by authorised persons)
Identify number(LOTO number) Isolated Equipment Location
1 1 Test
Operational Measure Types Validity From Validity Utill
Electrical 04-Feb-2025 10-Feb-2025
PERSON(S) COMPLETING THE ISOLATION
Name
Isolation Owner IO- Terminal1
Isolation Verifier IV Terminal1
I have personally checked the equipment to be worked on under this Isolation certificate and certify it to have
been isolated. Accidental reconnection of this equipment has been prevented by the following means:
Electrical Mechanical
Engineer LPI Isolation Certificate is certificate
and permit to work are withdrawn:
I certify that I have reviewed the Isolation Certificate is described in Permit Holder Name
proposed work and I am satisfied the permit to work is allowed
Contract Staff
that it is adequately described on between:
the permit to work and that the Permit Holder Date/Time
PI Name
precautions detailed are adequate
and clearly defined
Date/Time Permit Holder Reason
Name
Engineer PSP Terminal1 From
Is This Deisolate?
Date/Time 04-Feb-2025
LPI Name
04-Feb-2025 Until
10-Feb-2025 LPI Date/Time
LPI Reason
I have personally checked the equipment isolated above and confirm that work on it is completed and said
equipment has been re-connected and is in a safe working condition.
Name
Isolation Owner IO- Terminal1
Isolation Verifier IV Terminal1
Isolation Certificate-Lock out/Tag out No : 28
(To be completed only by authorised persons)
Identify number(LOTO number) Isolated Equipment Location
2 2 Test
Operational Measure Types Validity From Validity Utill
Instrumentation 04-Feb-2025 10-Feb-2025
PERSON(S) COMPLETING THE ISOLATION
Name
Isolation Owner IO- Terminal1
Isolation Verifier IV Terminal1
I have personally checked the equipment to be worked on under this Isolation certificate and certify it to have
been isolated. Accidental reconnection of this equipment has been prevented by the following means:
Electrical Mechanical
Engineer LPI Isolation Certificate is certificate
and permit to work are withdrawn:
I certify that I have reviewed the Isolation Certificate is described in Permit Holder Name
proposed work and I am satisfied the permit to work is allowed
Contract Staff
that it is adequately described on between:
the permit to work and that the Permit Holder Date/Time
PI Name
precautions detailed are adequate
and clearly defined
Date/Time Permit Holder Reason
Name
Engineer PSP Terminal1 From
Is This Deisolate?
Date/Time 04-Feb-2025
LPI Name
04-Feb-2025 Until
10-Feb-2025 LPI Date/Time
LPI Reason
I have personally checked the equipment isolated above and confirm that work on it is completed and said
equipment has been re-connected and is in a safe working condition.
Name
Isolation Owner IO- Terminal1
Isolation Verifier IV Terminal1
Lifting And Hoisting No : 28
Location Date and Time Zone
Test 03-Feb-2025 04:00 PM zone1
Operator Lifting Supervisor Validity From
operator supervisor 04-Feb-2025
Validity Until
10-Feb-2025
HAZARDS IDENTIFIED
Overhead Utilities / Obstruction Ground Conditions Underground Utilities
Test Test test
Vehicle & Pedestrian Traffic Pinch Point Fall Hazards
test test test
Other Equipment
equi
PRECAUTIONS
Spotter / Signal Person Elevated Warning Signs Cribbing / Shoring / Trench Plate
Spotter Elevated Cribbing
K-Rails / Jersey Barrier Caution Tape / Barricade Fall Protection
Barrie Barricade Protection
Other
other
LOAD CALCULATIONS
Width / Length / Height / Weight Number of Lift Points
10 10
Number of Slings Length of Slings
2 2
Distance Between Hook & Load Sling Tension
5 1
PRECAUTIONS
Diagram of Proposed Rigging & Slings (Include
LOAD INFORMATION
Measurements)
ePtw.jpg
ePtw.jpg
Lifting Inspector LPI Lifting Inspectator Certificate is
certificate and permit to work are
withdrawn:
I certify that I have reviewed the Lifting Inspectator Certificate is
proposed work and I am satisfied described in the permit to work is Permit Holder Name
that it is adequately described on allowed between: Contract Staff
the permit to work and that the
PI Name
precautions detailed are adequate Permit Holder Date/Time
and clearly defined
Date/Time
Name Permit Holder Reason
From
Date/Time
04-Feb-2025
LPI Name
Until
LPI Date/Time
10-Feb-2025
LPI Reason
Radiation Certificate No : 28
Valid only for routine activities involving ionise radiation source (To be completed only by authorised persons)
(To be completed by the permit holder)
Radioactive material being used,
Activity of material Contained within
specify
Active material
Radioactive
Manufacturer/Model Voltage Current
X-ray machine model1 1000 500
Other equipment
Additional information about operation of equipment Measures to prevent and mitigate exposure
test test
Radiation equipment will be
Additional controls required used between
From
test
03-Feb-2025 04:00 PM
Until
03-Feb-2025 04:00 PM
Validity From Validity Until
03-Feb-2025 09-Feb-2025
Engineer LPI Radiation Certificate is certificate
and permit to work are withdrawn:
I certify that I have reviewed the Radiation Certificate is described Permit Holder Name
proposed work and I am satisfied in the permit to work is allowed
Contract Staff
that it is adequately described on between:
the permit to work and that the Permit Holder Date/Time
PI Name
precautions detailed are adequate
and clearly defined lpi Terminal1
Permit Holder Reason
Name Date/Time
Engineer PSP Terminal1 17-Feb-2025
LPI Name
Date/Time From
lpi Terminal1
04-Feb-2025 03-Feb-2025
LPI Date/Time
Until
09-Feb-2025 LPI Reason
Risk Assessment No : 28
Risk Assessment of Date and Time
risk 04-Feb-2025
Staff List
test
Description of activity Description of equipment
test test
HAZARD ANALYSIS WORKSHEET
Hazards Identification Risk Assessment Text Risk Control Additional Control Those At Risk
1 1 1 1 1
Overall Assessment of Risk (using Risk
Assessment Matrix): Action needed: (inc Comments (if any)
responsible party and closeout target)
Test
Low
NON EXHAUSTIVE LIST OF HAZARD CATEGORIES
Electricity Noise
Lasers
Radiation Vacuum
Legionella
Weil's Disease Other Biological (Specify)
Psychological Hazards
High Pressure Explosion
Fire Hazard
Gas Vapor Release Toxic Chemicals
Flammable Substances
Hazard to eyes Hand Tools
Dangerous Machinery
Extreme of Temperature Confined Spaces
Working environment
Gravity (Height or above
Manual Handling
excavations)
Moving Vehicles
Cleaning Devices Slips, Trip, and Falls
Environmental Effects
Other
WHEN CONDUCTING A RISK ASSESSMENT
The assessment should be carried out in good time prior to the relevant decision being made When a specific
assessment is needed then such an assessment, rather than a generic assessment should be made The risk from
each activity should be considered A team of people or employees with practical knowledge of the process/activity
being assessed should be used as appropriate Consultants should be used where necessary All the hazards
associated with a particular activity should be considered Hazards and risk controls should be linked The results
of the assessment should be properly used.
PS Pipeline to provide high resolution image
HSSE Verifier
I certify that I have reviewed the proposed work and I am satisfied that it is adequately described on the permit to
work and that the precautions detailed are adequate and clearly defined
Name Date/Time
Method Statement No : 28
The Permit Issuer, when developing the respective Permit forms, will use the Method Statement supplied.
Company Project
Contracting Company true test
DESCRIBE THE CONFINED SPACE
Include site location drawings if appropriate?
9dcd5ecb-a555-490c-aa71-9bf2ae1f0c5d
Duration of work?
Are there any restrictions(e.g overhead power lines)?
nil
Any local permit required (local regulations)
nil
Any other details
work
Names of Responsible persons
Who is going to be working on the project?
test
Who will be in charge?
test
Who has specific responsibilities?(eg. plant , material,
etc)
plant
Who is to make contact with local authorities?
tester
Any other details
test
Plant and Equipment
What plant equipment and tools are required to do the
job?
equip
Tools (for work)
tool
Tool ( that may generate spark, ignitions source, etc)
spark
Others, Specify
test
What certificates, if any , are required for plant or
equipment?
gg
What training, if any, is required for operatives?
training
Communications with the workforce
How are the procedures, hazards to be
communicated to the workforce?
workforce
Start Date End Date
04-Feb-2025 10-Feb-2025
How work to be completed
test
PI
I certify that I have reviewed the proposed work and I am satisfied that it is adequately described on the permit to
work and that the precautions detailed are adequate and clearly defined
Name Date/Time
