PTW No.

TERMINAL ONE LIMITED

Work At Height 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 Expiry Time:

No. of Workers:

TOL WORK SAFETY

Work At Height

EQUIPMENT TO BE USED HAZARDS CONTROLS

Battery operated equipment Biological Hazard / Snakes Access Ladder
Camera Corrosive/Toxic Fluid Ambulance / Standby Vehicle
Chain block Electricity Area Barricading / Screening
Cold Tools Fall from Height Consider Adjacent Work (SIMOPS)
Carpentry Tools Falling Objects Emergency Equipment
Electric / Pneumatic drill Fatigue / Tiredness Fall Arrest Equipment
Grinder Flammable Material / Fluid Gas Monitoring
Masonry Tools H2S Gas Grounding (Equip / Welding / Heating)
Mechanical Cold Tools Hot Materials / Surfaces / Fluids Joint Inspection of Worksite
Scaffolding Materials Liquid / Gas Pressure Guard Rails (Top & Mid)
Scrapping / Painting tools Noise Non-Sparking / Insulated Tools
Sand Blasting Poor Illumination Process / Mechanical Isolation
Temporary Lights Scaffolding Collapse Radio Communication
Welding / Gas Cutting Slip / Trip / Fall Scaffolding Platform
Others Toxic Fumes, Vapors, Dusts Toe Boards
Other Radio Communication
Safe Access / Aggress
Safety Watch
Wind Direction Suitable
Wind Sock
OTHER CONTROLS: Other Controls
Nobody is allowed to carry mobile phone inside Hydrocarbon Area

Gas Test Result PPE & Safety Equipment

Date Gas / Dust Masks
Eye Wash Station
Time First Aid
Fire Extinguishers / Hoses
Oxygen Gloves
H2S Detector
LEL Personal Fall Arrest System
Welding Goggles
Other Welding Screen
Other
Signature Note: Mandatory PPEs (Safety Helmet, Safety Eyewear's, 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 mentioned isolation has been carried out: Name Sign Date Time

The work & precaution will be carried out under my overall responsibility. All personnel have been fully I / my representative have inspected the worksite. All hazards have been identified & all controls are in
briefed & understand the PTW / site HSE rules. 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 / cleanliness

Work Complete / 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