Permit No.

00001
COLD WORK PERMIT Original Copy-Page-1

Joint Job Site Inspection When Issuing and or Closing Out Work Permit is Required
LOCK AND TAG DETAILS:

WORK ORDER NO.

Unit/Area Equipment No.

Work description.

1-WORK
DESCRIPTION

What are the hazards associated with work scope? JSA Attached
2-RISK
ASSESSMENT YES NO

ITEMS DONE N/A ITEMS DONE N/A

A Equipment Isolated and Tagged
I Physical Restraint
B Lockout details entered in log
3-CONDITION C Lockout/Tagout the equipment Check area/Equipment condition for oil
J
OF AREA AND D Depressurize/Drain the Equipment spills or combustible materials
EQUIPMENT E Purge/Flush the Equipment K Scaffolding inspected & tagged
F Install Blinds(Attach Blind List) L Verify lifting equipment inspected
G Ventilate the Equipment M Handrail installed for open gratings
H Double block and bleed valve N Others.
Helmet Hearing protection Ground fault Interrupter
4-MANDATORY Gloves( ) Suit( ) Flagman/Rigger
PPE AND
Footwear( ) Respirator( ) Air Ventilation
SPECIAL
PROTECTION Safety Glass/Goggles SCBA/Airline BA Barricades & Warning Signs
Face shield Full body harness Orange vest

5-SPECIAL Interlock by-pass Yes No N/A

INSTRUCTION
Other Instructions:
Type of test 1st 2nd 3rd 4th 5th 6th
Is Gas Test required?
Oxygen 20.8%-21%
Combustible LEL < 10 %
YES NO
H2S< 10 PPM
Frequency CO < 25 PPM
6-GAS TEST Others:
Signature
Badge No.
I personally measured Authorization No.
these values Date
Time
7-APPROVAL WORK PERMIT ISSUER WORK PERMIT RECEIVER

Date: Name: Badge No. Name: Badge No.

Time: Signature: Auth No. Signature: Auth No.

Date: Renewed by: Badge No. Renewed by: Badge No.

Time: Signature: Auth No. Signature: Auth No.

Date: Renewed by: Badge No. Renewed by: Badge No.

Time: Signature: Auth No. Signature: Auth No.

8-JOB COMPLETION
Items N/A Yes No Name Signature Date Time
Receiver Is work completed
Is worksite cleaned and made safe
Locks removed
Worksite has been inspected
Issuer
Locks removed
Revision-0 EHS-S-000
 Permit No. 00001
COLD WORK PERMIT Carbon Copy-Page-2

Joint Job Site Inspection When Issuing and or Closing Out Work Permit is Required
LOCK AND TAG DETAILS:
WORK ORDER NO.
Unit/Area Equipment No.
Work description.
1-WORK
DESCRIPTION

What are the hazards associated with work scope? JSA Attached
2-RISK
ASSESSMENT YES NO
ITEMS DONE N/A ITEMS DONE N/A
A Equipment Isolated and Tagged
I Physical Restraint
B Lockout details entered in log
3-CONDITION C Lockout/Tagout the equipment Check area/Equipment condition for oil
J
OF AREA AND D Depressurize/Drain the Equipment spills or combustible materials
EQUIPMENT E Purge/Flush the Equipment
K Scaffolding inspected & tagged
F Install Blinds(Attach Blind List)
G Ventilate the Equipment L Handrail installed for open gratings
H Double block and bleed valve M Others.

Helmet Hearing protection Ground fault Interrupter

Gloves( ) Suit( ) Flagman/Rigger

4-MANDATORY
PPE AND
Footwear( ) Respirator( ) Air Ventilation
SPECIAL
PROTECTION
Safety Glass/Goggles SCBA/Airline BA Barricades & Warning Signs

Face shield Full body harness Orange vest

5-SPECIAL Interlock by-pass Yes No N/A

INSTRUCTION
Other Instructions:
Type of test 1st 2nd 3rd 4th 5th 6th
Is Gas Test required?
Oxygen 20.8%-21%
Combustible LEL < 10 %
YES NO
H2S< 10 PPM
Frequency CO < 25 PPM
6-GAS TEST Others:
Signature
Badge No.
I personally measured Authorization No.
these values Date
Time
7-APPROVAL WORK PERMIT ISSUER WORK PERMIT RECEIVER
Date: Name: Badge No. Name: Badge No.
Time: Signature: Auth No. Signature: Auth No.
Date: Renewed by: Badge No. Renewed by: Badge No.
Time: Signature: Auth No. Signature: Auth No.
Date: Renewed by: Badge No. Renewed by: Badge No.
Time: Signature: Auth No. Signature: Auth No.
8-JOB COMPLETION
Items N/A Yes No Name Signature Date Time
Is work completed
Receiver
Is worksite cleaned and made safe
Locks removed
Worksite has been inspected
Issuer
Locks removed

Revision-0 EHS-S-000
 COLD WORK PERMIT-INSTRUCTIONS
Page-2-Back Side

1.Cold Work Permit Examples:

Using basic hand tools Lubrication Blinding Inspection

Photography without flash Brush painting Adjusting instruments Taking measurements

Hand Excavation less than 1.2 Working on lines such as steam &
Voltage less than 24 V Scaffolding
meter depth acid line

Manual cleaning Housekeeping Cleaning strainers

Unit/Area: Enter the unit/area name and/or number. Equipment No./Location:Work Order No. Issuer and Receiver will discuss and understand the
description of the work to be performed. Give a clear, specific description of the work to be done. If attachment is required, it will be mentioned in this
section.

2.Risk Assessment:List all the hazards associated with the job and attach JSA.

3.Condition of area and equipmnt:

This section is used to specify how the equipment and work area is to be prepared before work begins.If one of the items is required and done, a
check mark (√) shall be entered in the "Done" column.If an item is not required, a check mark (√) should be entered in the "Not required" column.The
specific items in this section are defined as follows:A)Equipment Isolated and Tagged from all types of energy. B)Lockout details entered in log.
C)Lockout/Tagout the equipment.D)Depressurize the equipment.Depressurize means that the internal pressure of the equipment has been reduced
to zero (0) (atmospheric pressure) and, make sure to drain all the liquid from the equipment safely before issuing the work permit.E)Purge/Flush the
equipment-Is the responsibility of the work permit issuer to make sure that the equipment is purged/flushed properly and has been made safe before
the issuance of the work permit.F)Install blinds (attach blind list) If blinds are required to be installed. a blind list shall be attached to the work permit.
G)Ventilate the Equipment.H)Double block valve & bleed.The isolation of a piece of equipment by closing two positive shut off (holding) valves and
opening a bleed or drain valve in between. Care must be taken to ensure that the bleed valve is open and unobstructed. Install the tag on valves
whenever equipment is isolated, tags shall be affixed to the isolation device giving the name of the person who authorized the isolation and the
date.I) Physical Restraint- The isolation of equipment by physically restraining its movement.J)Check area/Equipment condition for oil spills or
combustible materials. K)Scaffolding inspected & tagged.L)Verify lifting equipment inspected.Attach lifting plan. M)Handrail installed for open
gratings.

4.Special Protection:

This section is used to specify the use of personal protective equipment including mandatory PPEs that normally required in the area.If special
protection is required, a check mark shall be entered in the box.If a specific piece of safety equipment is required, a check mark shall be placed in the
box to the right of the specific item.If something other than those items listed is required, the specific equipment shall be listed to the right of the word
"Others".

5.Special Instructions:

The use of clear and specific instructions is necessary to ensure proper communication before work begins.If there are no special instructions, a
check mark (√) shall be entered in the box to the right of the word "None".If interlock by-pass is required, check the box “Yes”, if not required, check
the box “No”, and if not applicable check the box “N/A”.If any other special instructions, procedures, or precautions are needed, they shall be listed to
the right of the word “Others”.

6.Gas Test:
If any gas testing is required prior to issuing the permit a check mark () shall be entered in the Yes/NO box.If a gas test is not required a check
mark () shall be entered in the No box.Gas tests shall be performed only by an Authorized Gas Tester .If additional gas tests are required during the
course of the work, the issuer shall specify the frequency at which gas tests must be repeated.The following information shall be listed:Oxygen
(20.8%). If oxygen test is required, the result of the test shall be entered in the space to the right. An oxygen content of 20.8% to 21% is required
before personnel may work in the area without self contained breathing air equipment.Combustible LEL (<10%) . CO(<25 ppm)/H2S(<10 ppm) gas
test is required, the result of the test shall be entered in the space to the right.
Note: If Flammability is not 0% LEL , means there is a hydrocarbon source. If Oxygen is less than 20.8 % in the air, means there are other gases
present or lack of oxygen. These situation could be very dangerous for the life of the workers.Special precautions must be taken. With the signature
the gas tester testifies that he measured the jobsite and that the values are true. LEL=Lower explosive limit. IDLH=Immediately dangerous to life or
health.

7.Approval

This section is used to record the signatures of those persons issuing, receving, and renewing the work permit. It is also used to record the dates
and times these activities took place. In case where two or more workmen are working on the equipment, the senior workman will normally accept
and sign off the Cold Work permit on behalf of his co workers.Permits are valid for only one (1) shift (8 or 12 hours shift). The maximum validity is 24
hours including any extension. Permits are to be extended only when the job is continuing and conditions are not changed. Authorized Issuers and
Receivers shall sign for each shift to extend a permit. In cases involving interconnecting equipment, it will be necessary for an authorized
representative from the adjacent area to endorse the permit prior to its issue. This may occur between units or within a single unit .
8.Job Completion

Issuer&receiver will conduct job site inspection/equipment upon completion of the work to close out the work permit, Even if the work is not
completed; verify that the work area has been left in a safe condition.If the job is completed, tick "Yes" and if the job is not completed tick "No".