= Project Title : 2017 NUI RELIABILITY & | FORM SS1 A PERTAMINA _|'INTEGRITY IMPROVEMENT PROJECT (SIDE 1) PHE ONWJ | Maintenance No : N/A ‘SH1 Number: ‘Work Pack No : FK 350P1$0002 SYSTEM SAFE CERTIFICATE ‘SITE: FK PF (See TYESINO [MGT CERTIFICATE No(s): FRG50P1S0002007 FOR SAFE SYSTEM OF WORK CONTROL MEASURES SEE THE REVERSE SIDE OF THIS FORM HANDOVER TITLE: HANDOVER INCLUDES NO | MCINo f ral | | ———pescripTiON REMAKS | FK 350 P15 002+07 Gas Lift Separator Gas Outlet to Instrument Gas Receiver ATTACH MARKED-UP DRAWINGS OF LIMITS OF SYSTEM / EQUIPMENT HANDOVER EXCLUDES: ‘OPERATING AUTHORITY HEREBY CONFIRMS THAT THE ABOVE SYSTEM AS DEFINED HAS BEEN ISOLATED AND ALL NECESSARY TESTS AND PRECAUTIONS|GARRIED OUT IN READINESS FOR SAFE WORK WITHIN THE BOUNDARY UMITS OF THE ISO M SIGNED pate_of of 20/7 INTENANCE’ ACCEPTANCE AUTH HEREBY ACCEPTS THE SYSTEM AS DEFINED SUBJECT TO THE RESPONSIBILITIES/LIMITATIONS AS SHOWN ON THE CONTROL MEASURES REFERENCED OVERLEAF. SIGNED ee : DATE_o8 Sar 2.0/7 7 Balto as Appropa DOUBLE SIDED FORMSSOW CONTROL MEASURES OPERATING AUTHORITY ‘SH1 NUMBER : FK 350P1S0002+07 AREA AUTHORITY OR DELEGATE STAGE 2 RISK ASSESSMENT (APPLICABLE *YES/NO) STAGE 2 RANo:_TFR- (28a- 20/7- o26! ‘SIGNED: hu DATE: oS Sert AOl7 TH ISOLATION CONFIRMATION (APPLICABLE *YESINO) ICC No:_TOA = 2.07) ~ 16 ~4n~ om? rine . SIGNED DATE: g@& Seer 2017 Tod: ‘SYSTEM FLUSH / PURGE / CLEAN SYSTEM FLUSHED / PURGED / CLEANED (APPLICABLE *YES/NO) SIGNED: DATE: ISOLATION MONITORING DOUBLE BLOCK & BLEED MONITORING IN PLACE (APPLICABLE YES/NO) SIGNED: DATE: OTHER CONDITIONS / PROCEDURES: HANDOVER INCLUDES WORKSITE WORKSITE IN A CLEAN AND SAFE CONDITION SIGNED: DATE: ‘SERVICES INSULATION / SCAFFOLDING COMPLETION SIGNED: ~Daiteas pproprate DOUBLE SIDED FORMa Project Title : 2017 NUI RELIABILITY & FORM SS1 M7 PERTAMINA — | INTEGRITY IMPROVEMENT PROJECT | (805 ») PHE ONWJ Maintenance No : N/A SH1 Number Work Pack No : FK 121P1S0004 SYSTEM SAFE CERTIFICATE SITE: FK PF HANDOVER TITLE: MCT APPLICABLE “VESINO_| MO1 CERTIFICATE No(s): FK121P1S0004+04 FOR SAFE SYSTEM OF WORK CONTROL MEASURES SEE THE REVERSE SIDE OF THIS FORM HANDOVER INCLUDES Fe] “Met No | _ DESCRIPTION REMAKS- ] | 1. | FKr2tPIs Test Header (iw internal coating) | | ‘004+04 | ATTACH MARKED-UP DRAWINGS OF LIMITS OF SYSTEM / EQUIPMENT HANDOVER EXCLUDES: ‘OPERATING AUTHORITY HEREBY CONFIRMS THAT THE ABOVE SYSTEM AS DEFINED HAS BEEN ISOLATED AND ALL NECESSARY TESTS AND PRECAUTIONS QABRIED OUT IN READINESS FOR SAFE WORK WITHIN THE BOUNDARY LIMITS OF THE ISOLATI sicnen_M. Al pate_08 Serr 207 (MAINTENANCE TANCE AUTHORITY HEREBY ACCEPTS THE SYSTEM AS DEFINED SUBJECT TO THE RESPONSIBILITIES/LIMITATIONS AS SHOWN ON THE CONTROL MEASURES REFERENCED OVERLEAF. SIGNED Ny Hho. pate_°2 Serr 20/77 Delete as Appropriate DOUBLE SIDED FORM