TOKA TINDUNG PROJECT

IZIN ISOLASI / ISOLATION PERMIT

NOMOR KOTAK KUNCI / LOCK BOX NUMBER :

A : APLIKASI / APPLICATION
Otorisasi Grup Isolasi di bawah izin / Authorise Group Isolation under permit.
\
B : LINGKUP KERJA DAN KETERBATASAN / WORK SCOPE AND LIMITATIONS
Keterbatasan kerja yang teridentifikasi selama survei/ Limitations of work as identified during survey:

Lingkup kerja yang diusulkan / Scope of proposed work:

C : SPESIFIKASI ISOLASI / SPECIFICATIONS OF ISOLATION

Judul peralatan: Kode peralatan:
Equipment Name: Equipment ID Code:
Tanggal isolasi: Waktu isolasi:
Date of isolation: Time of isolation:
PERSYARATAN ISOLASI / ISOLATION REQUIREMENTS

Nomor Isolasi
Titik Wajib dalam Isolasi Verifikasi
Unit identifikasi dilakukan dan
Gembok isolasi semua kasus kode isolasi (Initial)
terkunci (Initial)
Isolation Verification of
Lock Point of Mandatory in Isolation
Unit identification effected and isolation
Number isolation all cases code
locked (Initial) (Initial)

Isolation codes: VLO – Valve Locked SI – Spade Inserted

LVI – Low Voltage Electrical Open RI – Radiation Isolation

Reviewed : Originator: D. Watson / Operations Mgr: R. Fleeton / Chief Operating Officer: D. Morrison
Revision: A Rev Date: 20/06/12 Expire Date : Department: OHS Document Type: Form
Last printed 5/25/2020 7:50:00 AM Page 1 of 4
 TOKA TINDUNG PROJECT
IZIN ISOLASI / ISOLATION PERMIT
SR – Spool Removed HI – Hydraulic Isolation
(blank fitted) MI – Mechanical Isolation
HVI – High Voltage Electrical
GI – Gravitational
DCR – De-Contractor Removed
Isolation
VLC – Valve Locked Closed
PD – Physical
Demarcation
D : TAMBAHAN KONTROL RESIKO / ADDITIONAL RISK CONTROLS
Wajib dalam
Item Kontrol Dilakukan (Initial) Penyerahan 1 dengan cek
semua kasus
Mandatory in Handover 1 with check
Item Control Effected (Initial)
all cases (Initial)

E : OTORISASI / AUTHORISATION
Authorised
Isolator Nama / Name Tanda tangan / Signature Tanggal/ Date

Authorised
Isolator
Handover 1. Nama / Name Tanda tangan / Signature Tanggal/ Date

Authorised
Isolator
Handover 2. Nama / Name Tanda tangan / Signature Tanggal/ Date

Authorised
Isolator
Handover 3. Nama / Name Tanda tangan / Signature Tanggal/ Date

F : PENUTUPAN / CLOSURE
Authorised
Isolator Nama / Name Tanda tangan / Signature Tanggal/ Date

Reviewed : Originator: D. Watson / Operations Mgr: R. Fleeton / Chief Operating Officer: D. Morrison
Revision: A Rev Date: 20/06/12 Expire Date : Department: OHS Document Type: Form
Last printed 5/25/2020 7:50:00 AM Page 2 of 4
 TOKA TINDUNG PROJECT
IZIN ISOLASI / ISOLATION PERMIT

G : APLIKASI GEMBOK PRIBADI / APPLICATION PERSONAL LOCK

Reviewed : Originator: D. Watson / Operations Mgr: R. Fleeton / Chief Operating Officer: D. Morrison
Revision: A Rev Date: 20/06/12 Expire Date : Department: OHS Document Type: Form
Last printed 5/25/2020 7:50:00 AM Page 3 of 4
 TOKA TINDUNG PROJECT
IZIN ISOLASI / ISOLATION PERMIT
Time removed and
Name Time applied and signature
signature
Waktu pemasangan dan Waktu pemindahan dan
Nama
tanda tangan tanda tangan

Reviewed : Originator: D. Watson / Operations Mgr: R. Fleeton / Chief Operating Officer: D. Morrison
Revision: A Rev Date: 20/06/12 Expire Date : Department: OHS Document Type: Form
Last printed 5/25/2020 7:50:00 AM Page 4 of 4