TERMINAL ONE LIMITED PTW No.

COLD Work Permit

To be Issued by Authorized Authority Only

Area Classification PTW Applied By: Dept: Start Date:

Work Location: Start Time:

Hydrocarbon area
Work Description: Expiry Date:

Non-Hydrocarbon Area No. of Workers: Expiry Time:

TOL WORK SAFETY

Confined space entry Work at height Excavation
Energry Isolation Gas Test Ground Disturbance

EQUIPMENT TO BE USED HAZARDS CONTROLS

Analyzer Biological Hazard / Snakes Additional Lighting
Battery operated equipment Confined Space Entry Adequate Ventillation
Camera Corrosive/Toxic Fluid Ambulance / Standby Vehicle
Carpentry tool Electricity Area Barrication / Screening
Chain block Fall from Height Area free of Flammable / Combustible Material
Compressor Falling Objects Confinded Space Attendant
Electric / Pneumatic drill Fatigue / Tiredness Consider Adjacent Work (SIMOPS)
Grinding Flammable Material / Fluid Dewatering
Masonry tool H2S Gas Draining / Purging / Flushing
Mechanical cold tools High Wind Emergency Equipment
Mobile crane Hot Materials / Surfaces / Fluids Equipment Inspection Checklists
Motor Pump Lifting Operation Gas Monitoring
Motor Vehicle Liquid / Gas Pressure Grounding (Equip / Welding / Heating)
Powered steel wire brush Noise Joint Inspection of Worksite
Sand blasting O2 Deficient / Enriched Manual Excavation
Scaffolding tools Poor Illumination Material Safety Data Sheet
Scrapping / Painting tools Slip / Trip / Fall Non-Sparking / Insulated Tools
Temporary Lights Spillage Process / Mechanical Isolation
Welding / Gas Cutting Static Chrages Radio Communication
Others Toxic Fumes, Vapors, Dusts Safe Access
U/G Cables Safety Watch
OTHER CONTROLS: Vehicle Movement Wind Direction Suitable
Nobody is allowed to carry mobile phone inside Hydrocarbon Area Weather (Hot, Cold, Foggy) Wind Sock
Other OTHER CONTROLS

Gas Test Result PPE & Safety Equipment

Gas / Dust Masks
Date
Eye Wash Station
Fire Extinguishers / Hoses
Time
Flame / Heat Resistant Clothing
Gloves
Oxygen
H2S Detector
Personal Fall Arrest System
LEL
Welding Goggles
Welding Screen
Other
Other
Note: Mandatory PPEs (Safety Helmet, Safety Eyewears, Coverall, Safety Shoes) must be
Signature worn all the time during execution of job

Energy Isolation
Valves Closed Tag out Lock out Fuse removed
Process Isolation Bypassed Isolated Electrical Isolation Tag out Connections removed
Lock out Switched Off Isolated Circuit breakers off
Lock out Safety override Valves Closed Lock out
Control/Instrumentation Isolation Mechanical
Tag Out Out of service Isolation Blind Disconnected
Isolated Tag out Positive Isolation

I declare that the above menioned isolation has been carried out: Name Sign Date Time

The work & precaution will be carried out under my overall responsibility. All personnel have been I / my representative have inspected the worksite. All hazards have been identified & all controls
fully briefed & understand the PTW / site HSE rules. are in place. All other persons affected/impacted by this PTW have been informed of the scope of
work, hazards and controls. It is now safe to perform the specified work till the given expiry date &
time.

PTW Receiver / Perf. Authority PTW Issuer

PERMIT CLOSURE (Completion / Suspension)
The work for which this PTW was issued has been properly performed, personnel, work tools, equipment & apparatus have been removed and all the
equipment, plant & electrical apparatus affected by the work have been left in a safe and clean condition.

Work COMPLETE and Resume normal operations subject to area closure/cleanilness

Work INCOMPLETE / Work SUSPENDED

PTW RECEIVER / PERF. AUTHORITY PTW ISSUER / AREA AUTHORITY

Date & Time:

* Permit is prepared by HSE Department.

Note:
1. Kindly close the permit within one day after expiry date of PTW.
2. Proper housekeeping should be implemented prior closing the PTW by the permit issuer.
3. Kindly implement above mentioned controls/PPE