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FM-ALL-OAS-21.01

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Revisi :01
Terbit :26 Feb 2015

WORK PERMIT SYSTEM

(SISTEM BUAT - IZIN KENA)

Thispermitshould be issued whenever 1 lzin lnrus dikeluarkan bilomaM I

-gasor electric weidln& gas cutting or anywork which creates sparks visible in daylight is carried out outside ol
permitted areas.

pengeloxn dan pemotegan dengan menqgumkan li$nk atuupun go., otou Wkerjddn apdpun ydng dopdt menimbulkdn
rPrcikon dpi yong tanryk Ndo nang hari dilokukan di luar drel yang diizinkon

- isolation of any energy murce is required.

pemisdhdn ddri *tiap sumber erergi yong diperlukon

Note : Additionai permits may be required Permit number must be sequental with register
Cotdton : lzin tonbahon munqkin diperlukdn lzin hor6 di daftdrkan

ffi
Location of work/lotosi Pekerimo I
Details of Worly'Per:trEn Pekeriaan I

Authorisd PersoM Ordno vand Beruevenono I

qsistantlsl/PcMfi-rrn :

Type of Work : Elertrical Welding 6*W€lding Gas Cutting Grinding Other

G6 Peketjaon Pokoi
lenis Pelerjoqn: Peruelos Pakai Loinnyo
Pctucldq Pdkdi Li.trik 6^?^6, dU.i Gd< Geinda

Preparation for Work :

Pe?siapan untuk kerja i

Ensure that the following hazards are recognisd by all per$ns and that the controls are in place
Pastikon bohwo bohayo-bohayo berikut dimengerti oleh *mw orong dan dopdt diatosi egeru di tempot

Hzzads/ Bohola2 : :ontrols/ Pengendalian : Checked :

Fi?e / t(€bakoran: Are free of flammable material & hpou.s

Tidok ada bohon / uop vono mudah terbokat
learby hazards removed/covered
,ohayd yong terdekdt sudah dipindoh / ditutup
Fixed extlnguishing systems ready for use
Sistem oemadoman IAPAR) wno sidp ookdi tersedio
:ire main pre$urised
,omDo utom untuk Modam kebdkoron sioD diDakai

Hoss and extinguishers ieadyfor use

*long-selong don aldt pemodom siop untuk dipakoi
Extinguishers of appropriate type
tenis EnE olot oemodom IAPAH teldh %uai
\rea thoroughly ventilated
bluruh oreal mmiliki ventilosi udara vdnq ukuD
:ire mtch-as posted
Tenaowmn kebokoron-sesuai defroan daftor vaM dirmufrkan

Eeneral / Hal Umum All equipment in good order

semua peralaton berada ddlam kondig wng bdik
:orrect PPE used
qlot Pelinduna Ari t€loh diounakan denoon benat
:scape routes clean
taldn kelwr darurot terbukd dan tidak ado holdnaon

PAGE 1 OF 2 FORM NO.: FO - P.s2 / R0

 (BIBIGhfl{AE C6}$} il',

Other departmentsthat haye been warned :

Eagian lain harus sudah diiftloffidsikon :

This permit is valid from : hrs. to : hrs- on the date shdwn-

Surat lzin tnl mutai berloku *j*: somwi lam; padd tsnagal yong tertebut

The Authorised Person above is permitted to carry out the work as speclfied.
yong dibeil kewenongan diotdt diizinkdn untuk mlokxmkan pekerjoon esuoi Wng diterangkdn

/ fanda Tarqdn i
HsE Officer

undertake to carry out the work as specified and I undeGtand the hazards and controls
akon melokwwkon pek*joan sesuai keterungan ddn fiya meildhomi bdhoyo dan percegohan

/ Tonda Tangon : Posilion / ldwon i

lssued until hours: Signed:

tiln : TondoTonoon: Hs

The abore work was completed safely at: hours: date: Signed /Tandotongnn
di atos selesai dengon elomot Nda: jam: tonggol:

at:
fhe above work was completed sfeiy hours: date;
didtasselesidengonslomotpddo: jom: tdnggal: ,

worksite was inspected and accepted as

work completed, all materials and equipment Signature of inspector
and the area clean. fandd tdngan Pemiliko
lempat kerioteloh diryrikx don ditedma ebdgdi Name of inspector:
Wg teloh *lffii, seluruh bahon don l,lama Pemerikfi:
tetoh dioindahkon: don oreat teldh berih. btOE

wo* permit accepted as closed hours: date: $gned/TaMotongon

kela initelah diterino *bogoi jom: tonggdl:

HSE Oflicer

i.

PAGE 2 OF 2 FORM NO.: FO - P.02 / R0