Work Authorization and LOTO Permit Request Form

Project Location: JIGCC (Package 4) Date: 02/02/_2020_ No.: ______________

WORK REQUESTED BY: TITLE:

SYSTEM: UNIT-32 CONTROL OIL SYSTEM PHONE #:

DESCRIPTION OF WORK TO BE PERFORMED

CONTROL OIL PRE CLEANING PUMP BUMP TEST AND CONTROL OIL PUMP START FOR
OIL FLUSHING

A10-GM-3211 A/B
(TO BE FILLED OUT BY SUPERVISOR CONDUCTING WORK) (CHECK ONE)

Construction Permit to Work (PTW) #_____________________________________

Check appropriate permits: Job Safety Analysis ☐

Hot Work Permit ☐
Confined Space Permit ☐
Excavation Permit ☐
Permits Approved:
(WORK SUPERVISOR) (Date)

Known Hazards in Work Area:

(TO BE FILLED OUT BY COMMISSIONING)

Does Work require LOTO to be applied? YES / NO

If yes, LOTO Permit Number related to Work Authorization #_________

Have workers signed on the LOTO Permit Sign-in/Sign-out Form? YES / NO

Will Work be completed today? YES / NO

If No, date in which work will be completed. __________

WORK PERFORMED BY:

(WORK SUPERVISOR) Date
WORK APPROVED BY:
(COMMISSIONING) Date
LOTO ADMINISTRATOR:
(COMMISSIONING) Date

RETURN ORIGINAL FORM TO COMMISSIONING UPON COMPLETION OF WORK

Reference : SES-PGB-HS-PRO-0027 Commissioning Work Authrozation and Loto Permit Request Exhibit B