Tool C - Sample Lockout/Tagout Safety Permit Lockou

Lockout Tagout Permit Date:

Time issued:
Permit Issued to: Expiration time:

Client Subcontractor Name:

Job description:

CHECKED PRECAUTIONS SHALL BE OBSERVED PROTECTIVE EQUIPMENT REQUIRED

TAG & DISCONNECT FIRE EXTINGUISHER WEAR GOGGLES WEAR RUBBER

ELECTRIC EQUIPMENT AT SITE FACE SHIELDS BOOTS
LINES BLINDED CONTAINS SPARKS WEAR GLOVES WEAR SAFETY
RUBBER THERMAL BELT & LINE
VALVES CLOSED & KEEP AREA FREE OF WEAR HOOD WEAR RESPIRATOR
TAGGED COMBUSTIBLES ACID THERMAL DUST CHEMICAL
LOCKED OUT BARRICADE AREA WEAR SUIT
RUBBER THERMAL
LINES DISCONNECTED SHIELD ARC

BLEEDERS OPEN

OTHER PRECAUTIONS:

PERMIT CONDITIONS AND REQUIREMENTS UNDERSTOOD APPROVALS

SUPERINTENDENT TIME

PLEASE CIRLCE ONE: SIGNED PROJECT MANAGER TIME

ENGINEER | FOREMAN
OTHER TIME

Work must begin within ninety minutes of issuance of this permit.

If the work is interrupted the foreman craftsman, or subcontractor must indicate equipment condition to superintendent
or project manager when leaving job for more than one hour or when job is complete.

JOB COMPLETE JOB INCOMPLETE

THIS PERMIT IS TO BE KEPT ON THE JOB UNTIL WORK IS COMPLETED, PERMIT EXPIRES OR IS REVOKED