FO-SHE-03

LOCKOUT-TAG OUT PERMIT

WAREHOUSE: DATE: PERMIT NO:

DESCRIPTION OF WORK TO BE UNDERTAKEN:

NOTE: All work to cease on sounding of fire alarm. Work area and equipment to be made safe at any time during the period of the permit.
MECHANICAL ISOLATION
Equipment Closed Disconnected LO/TO? Other
YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO
Mechanical system isolated by:

Name Position Signature

ELECTRICAL ISOLATION
Equipment Isolated Zero Voltage LO/TO? Other
YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO
YES/NO YES/NO YES/NO
Electrical system isolated by:

Name Position Signature

I declare the precautions specified in this permit have been properly carried out in accordance with
RESPONSIBLE PERSON relevant procedures & safe working practices.

Name Position Signature

I confirm the precautions specified in this permit have been properly carried out in accordance with
AUTHORIZING PERSON relevant procedures & safe working practices.

Name Position Signature

ISOLATION REMOVAL
Mechanical Isolations Removed by:

Name Position Signature

Electrical Isolations Removed by:

Name Position Signature

COMPLETION
I declare the isolations required in this permit have been removed and the system is
RESPONSIBLE PERSON returned to normal operating status

Name Position Signature

AUTHORIZING PERSON I confirm the isolations required in this permit have been removed and the system is
returned to normal operating status. This permit is cancelled.

Name Position Signature

Revision No.: 01 Effectivity Date: September 15, 2019

Date of Revision: May 31, 2023