PTW No.

TERMINAL ONE LIMITED

Confined Space Entry 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 Energy Isolation Gas Test

EQUIPMENT TO BE USED HAZARDS CONTROLS

Battery operated equipment Biological Hazard / Snakes Additional Lighting
Camera Confined Space Entry Adequate Ventillation
Chain block Corrosive/Toxic Fluid Ambulance / Standby Vehicle
Cold Tools Electricity Area Barrication / Screening
Electric / Pneumatic drill Fall from Height Area free of Flammable / Combustible Material
EX-Proof Tools Falling Objects Confinded Space Attendant
Grinder Fatigue / Tiredness Consider Adjacent Work (SIMOPS)
Motor Pump Flammable Material / Fluid Dewatering
Scrapping / Painting tools H2S Gas Draining / Purging / Flushing
Temporary Lights Hot Materials / Surfaces / Fluids Emergency Equipment
Welding / Gas Cutting Liquid / Gas Pressure Gas Monitoring
Others Noise Grounding (Equip / Welding / Heating)
O2 Deficient / Enriched Joint Inspection of Worksite
Poor Illumination Non-Sparking / Insulated Tools
Slip / Trip / Fall Process / Mechanical Isolation
Spillage Radio Communication
Toxic Fumes, Vapors, Dusts Safe Access / Agress
Other Safety Watch
Other Controls

OTHER CONTROLS:
Nobody is allowed to carry mobile phone inside Hydrocarbon Area

Gas Test Result PPE & Safety Equipment

Date Gas / Dust Masks
First Aid
Time Fire Extinguishers / Hoses
SCABA
Oxygen Gloves
H2S Detector
LEL EX-Proof Tools / Equipments
Welding Goggles
Other Welding Screen
Other
Signature Note: Mandatory PPEs (Safety Helmet, Safety Eyewears, Coverall, Safety Shoes) must be
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
Control/Instrumentation Isolation Lock out Safety override Mechanical Isolation Valves Closed Lock out
Tag Out Out of service 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

Date:
Time: PTW RECEIVER / PERF. AUTHO: PTW ISSUER / AREA AUTHORITY

* 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