PetroChina (Halfaya) Permit To Work System

EXCAVATION CERTIFICATE No.:

I. TASK
Brief description of the proposed task: Work Request Period (Planning)
From Date Time
To Date Time
Work Permit Number: Permit Type Hot Work Permit Cold Work Permit

Location: Excavation Digging Wall Penetration

Name (Certificate Originator): Signature & Contact No.: Date Time

II. WORK TYPE

YES NO YES NO Supporting Documents YES NO Attached & Number

Trenching Driving of pickets, electrodes, pin, spike, pipe, nails, Job Hazard Analysis
Drilling etc. Method Statement
Ground Ripping Demolishing Toolbox Talk
Foundation Sawing Drawings
Post Holes Penetrating into walls SIMOPS
Other, specify: Other, specify: Other, specify:

III. DISCIPLINE AUTHORISATIONS

Discipline Engineer Conditions (if any) Name Signature Date

Instrumentation
Control Systems
Corrosion
Production Operations
Mechanical
Electrical
IT / Communications
Other, specify:

IV. GENERAL CONSIDERATIONS

Design Considerations YES NO HSE Considerations YES NO

All utilities and underground services identified and marked? PTWs required for all work in or around the excavation?
All underground services de-energised/de-pressurized and locked and tagged before breaking
Barriers erected around deep excavations to prevent personnel from falling in?
ground?
Sloping, benching or support systems being used? Have these been approved by a competent
Roads, pathways identified and barriers erected to manage vehicles and foot traffic?
person (subject matter expert)?
Adequate access/egress provided (minimum every 7.6m / 25 feet)? Warning signs erected near excavation sites?
Requirements for daily inspections identified (or as conditions occur that may affect or create
Is a soil compaction test required?
hazards)?
Will excavation be left open overnight? Provide covering, visible barriers or warnings/lights to
Does design, or soil conditions prevent cave-in? If not sloping benching shall be used?
prevent personnel from falling in.
Heavy / earth moving machinery is not to be used within 5m of underground services, pipelines,
Vehicles positioned to prevent exhaust fumes entering excavation?
etc.?
Spoil piles kept at least 2m from edge of excavation? Spoil and equipment positioned to prevent falling into excavation?

Stop logs' considered in high traffic areas to prevent vehicles falling into excavation? Exclusion zone designated around top of excavation or fall protection provided?

Design prevents or minimises chance of water ingress? Ventilation required?

Emergency response actions understood by all persons for all underground services that may be
Adjacent structures identified and considered to prevent loss of stability?
expected?

V. SPECIALIST REVIEW (Civil Engineer) (To be determined by Permit or Certificate Issuing Authority)
Specialist Review Required? (circle as necessary) YES NO

Name Signature Contact No. Speciality

Comments: Date
Time
VI. CERTIFICATE APPROVAL AND ISSUANCE
PERFORMING AUTHORITY AREA OPERATOR / CUSTODIAN
I understand the work scope and accept the conditions and precautions specified in this certificate. I will explain them to the work party through a toolbox talk I declare that all hazards have been identified and all specified control measures are in place and it is safe to carry out the work defined.
prior to commencing the work and ensure adherence throughout the work. I fully accept the responsibility to carry out the above work in the safest possible
manner.

Name: Name:

Employee No.: Employee No.:

Signature: Signature:

Date/Time: Date / Time:

VII. CERTIFICATE EXTENSION / RENEWAL (For extended period, Additional Sheet For PCH Work Permit Extension may be attached to this certificate)
PERFORMING AUTHORITY AREA OPERATOR / CUSTODIAN
Date Time
Name Signature Name Signature

VIII. CERTIFICATE CLOSURE

PERFORMING AUTHORITY AREA OPERATOR / CUSTODIAN
I declare that the work has been completed, worksite is clear, housekeeping is satisfactory and the equipment affected is left in a safe condition. I have inspected the equipment/work area and declare that the work defined in this certificate is complete and that the area is clean and safe.

THE EXCAVATION CERTIFICATE IS NOW CLOSED

Name: Name:

Employee No.: Employee No.:

Signature: Signature:

Date/Time: Date / Time:

Top Copy: Performing Authority (To be displayed at job site) Second Copy: Permit Control Facility/CCR Third Copy: Permit Issuing Authority

NOTE: This certificate is valid only when used with a valid work permit. This certificate alone does NOT authorise any task to be performed. Version 2.1 Jan 01 2018