Form No.

: MHC-HSSE-HSE-FM-01
SAFETY PERMIT Edition No. : 1
Effective Date : December 7, 2021
HEALTH, SAFETY, AND ENVIRONMENT Page No. : 1 of 1

January 8, 2021
Date/Time Requested : ______________/________ 14:32 January 8, 2022
Expected Date of Completion: ________________
Nature of Work/Services :
☐ Electrical Work ☐ Hot Work ☐ Civil Work
☐ Work in Confined Spaces ☐ Mechanical Work ☐ Chandling
☐ Others (please specify): _______________________________
Solicitation of Provision
Work/Activity Description: ____________________________________________ MV Shinline 12
Location: _____________
Request Granted to : ____________________________________Contact
Bernie and AMV no: ____________________
Person/s to do work : _________________________________________
DOLLY CABALLERO, CANDICE LLAGUNO (Use separate sheet)
CRISELDA SALVO, SHIELA SALVO (Personnel to board should be limited only)

☐ WORK PERMIT REQUEST (WPR) ☐ GENERAL SAFETY REQUIREMENT

Safety Protective Equipment and Safety
Work/Area Requirement
Check Apparel Check
1. Area clear of combustible materials 1. Safety Shoes
2. Equipment completely isolated/de-
2. Safety Helmet/Hard Hat
energized
3. Area of equipment adequately lighted &
3. Gloves
ventilated
4. Area tested gas free & safe to work 4. Face Shields/Goggles
5. Welding machine in good operating
5. Safety Vest
condition
6. Adequate entry & exit facilities 6. Full Body Harness/Safety Line
7. Warning signs in place 7. Safety Net
8. Source of power, water, etc., requested &
8. Fire Extinguishers
provided
9. Firefighting facilities & equipment ready &
9. Others: face masks
manned

☐ VESSEL SERVICE REQUEST (VSR) ☐ DOCUMENTS PRESENTED

Activity Safety Description Safety
Check Check
1.Ship’s Supply Delivery 1.BOC processed docs
2.Bunkering 2. PPA processed docs
3.Repair 3. Shipping Line’s letter
4. Survey 4. MHCPSI processed docs
5. Others: 5. Others: Receipt from Billing

☐ HAZARD IDENTIFICATION and CONTROL

List Of Possible Hazards Actions To Be Taken
Slips, trips and falls Maintain physical distancing of 2m
Vehicular hazards Follow 20kph rule
Illnesses Wear properly the prescribed PPE stated above

I hereby conform to the conditions discussed during the briefing/orientation given by the HSE Office regarding the implemented rules
and regulations inside the Terminal.

Requested by: Approved by:

__________________________________ Marwin Vincent M. Balba

________________________________
Signature over printed name HSE Section, MHCPSI

This document is a property of Manila Harbor Center Port Services Inc., any part thereof should not be replicated in any form. Only the documents/forms published on the ISO Portal, and those
printed and signed by the department authorities, shall be considered latest and valid. Unsigned printed copies are considered uncontrolled and, therefore, invalid.