Permit to Work Form HSF-OP-446-0001 Permit Date: Time of issue: Description of work: Rev No: A Job No: Period

of validity: Issue Date: 07-Jul-2010 Page 1 of 1

Location of Work: Systems to be isolated: Hazards:

Risks:

Control Measures:

Details of protective Equipment to be used:

Any other Person/department to be notified: Method statement is attached Issued by HSE Engineer: I hereby declare that I understand the content and no other work other than the stated above is to be carried and all proposed and any additional control measures as additionally deemed necessary at any time will be adhered to. Name: Received by Maintenance Supervisor: I hereby declare that I understand the content and no other work other than the stated above is to be carried and all proposed and any additional control measures as additionally deemed necessary at any time will be adhered to. Name: Signature: Signature: Yes No (if no specify):

Prepared by: Daniel Scott Department: Quality Checked by: Mohamed Al Reyami Department: HSE Approved by: Ali Askari Department: QHSE & Security Rev. A Issue Date 07-Jul-10

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