FORM 1

ACCESS PASS FORM

Date Requested: Oct. 09, 2023
Ocular Visit, to check/inspect the FDAS
Activity/Event: and Fire Pump System Activity/Event Date: Oct. 11, 2023
Location: Brgy. Tibasan, San Miguel Bulacan Control No.: PFBSI-APF-

Personnel List and Log Sheet:

Permit Validity Period
Name Company Name Date Time
From To From To
Albert Kalaw Fireprofessionals(firepro), Inc. 10/11/23 10/15/23 10am 5pm
Deus Kalaw Fireprofessionals(firepro), Inc. 10/11/23 10/15/23 10am 5pm
Anaclito Macahilig Fireprofessionals(firepro), Inc. 10/11/23 10/15/23 10am 5pm

List of Materials to be Used

Description Electrical Specification Description Quantity Remarks
Basic Hand Tools 1 set
Multi-Tester 1 set
Vehicle Details (Driver Name & Plate
No. ANDYQUINTIA/NDJ 1132

Purpose Ocular Visit to check/Inspect the condition of FDAS and Fire Pump System.

This form must be properly filled-out by the requesting office/company and approved by Security and the authorized Safety Officer before
any activity or work can proceed. For the orderly conduct of the activity, please observe the following guidelines:
1. Smoking is strictly prohibited inside the compound except at designated smoking areas. No loitering to places other than the specified location.
2. IDs of outsourced service provider, event organizer, vendor or visitor must always be worn while inside the Plant premises.
3. Proper working clothes must be observed and wearing of Personal Protective Equipment must be observed.
4. Use of open fire and wax burner by catering service in indoor venues is not allowed. Only the use of electric food warmers or heat lamps shall be
permitted.
5. Damage to Company properties as a result of the activity shall be the responsibility of the service provider, event organizer, vendor, or visitor.
6. Affected finishes shall be restored to match the original and subject to our final assessment and approval.
7. Everything brought inside the premises shall leave the premises after every scheduled activity.
8. No work that is not included in the approved plan shall commence without permission from Security.
Only those personnel from outsourced service providers, event organizers, vendors or suppliers who have completed the required security and safety
orientation shall be allowed access inside plant premises. (Safety orientation schedule: Every Friday, 7:30 AM, at Security Office. For urgent activities,
kindly coordinate with Organizational Safety.

Requested by:
Anaclito Macahilig/09176318668 Oct. 09, 2023
Service Provider/Company Representative DATE
(Printed Name, Signature and Contact No.)

Endorsement/ Bulacansol:

BULACANSOL Admin DATE

(Printed Name, Signature and Contact No.)

BULACANSOL Control Room Engineer DATE

(Printed Name, Signature and Contact No.)

BULACANSOL Shift Charge Engineer / Site Head DATE

(Printed Name, Signature and Contact No.

Note: The approved document must be presented when required during the duration of the work/event/activity.
 PERMIT TO WORK FORM

PFBSI-OM-PTW-01 REV. X
Oct 11 to 15, 2023
EFFECTIVE DATE: _______________

Persons undertaking this work must comply with all relevant Occupational Safety and Work Order/Service Request No.
Health (OSH) legal requirements, policies, and procedures. Only the work specified is
to be carried out and the work area must be left in a safe and tidy condition at all
times.
Work Permit No. (c/o Control Room)
THIS WORK PERMIT MUST BE AVAILABLE UPON INSPECTION

NAME OF ACTIVITY/PROJECT:
Ocular Visit, to check the condition/Inspect of FDAS and Fire Pump System
STATE SPECIFIC LOCATION OF WORK: PERMIT VALIDITY PERIOD (maximum of 30 days)
Start Date: Oct 11, 2023 Start Time: 10am
Fire Pump System Area
End Date: Oct 15, 2023 End Time: 5pm
TO BE FILLED OUT BY SAFETY OFFICER OR SHIFT SUPERINTENDENT/HIS DESIGNEE IF S/O IS UNAVAILABLE
(Check applicable required documents to be submitted)
SAFETY ASSESSMENT AND APPROVAL

Hazard Aspect Identification Risk Impact Assessment Yes N/A Yes N/A

and Control (HAIRIAC) Table / Third-party certificates for heavy equipment /

8-Hour Mandatory OSH Training Certificates for all
/ Skilled Worker’s Certificates/Training (NC II) /
workers engaged in the activity
Scaffolding Permit / As built plan/drawings for excavation activities /
Equipment Clearance Form (For LOTOTO) / Lifting plan for mobile crane lifting activities /
Tool Tape Inspection Form (Power Tools, Ladders,
/
Training Certificate of Safety Officer and First-Aiders /
Fall Protection & Lifting Equipment) (for contractors only)
Gantt Chart (for engineering projects/ construction Safety Data Sheets (SDS) when handling hazardous /
activities) / chemicals

This is to confirm that the required documents, as stated above, have been received and reviewed by the undersigned and has met the OSH legal
requirements and GBP’s OSH Policy and Procedures.
Name & Signature: Date & Time: Tracking Number:
(for Safety Team only)
SAFETY OFFICER/PERMIT ISSUER

TO BE FILLED OUT BY SERVICING GROUP

PERSON IN CHARGE: “I confirm that I have verified the job detailed on this form and ensured that all necessary precautions have been taken. The
work will be carried out/implemented in a safe manner, in accordance to the established OSH policies and procedures. All risks and precautionary
AUTHORIZATION & ACCEPTANCE

measures have been explained to all workers involved.”

Name & Signature: Job Designation: Department/Company (if contractor)
Anaclito Macahilig Tech'n Fireprfessionals(firepro), Inc.
AUTHORIZED PERMIT HOLDER

TO BE FILLED OUT BY OPERATIONS/O&M DEPARTMENT

PERSON AUTHORIZING WORK: “This permit will be issued on the understanding that all agreed safe systems of work will be adhered so that any risk
or hazard shall be maintained at a level as low as reasonably practicable.”
Name & Signature: Job Designation: Department:

PERMIT ISSUER
TO BE FILLED OUT BY SECURITY DEPARTMENT
SECURITY IN CHARGE: “I confirm that the third party is free from illegal drugs and deadly weapons. The materials and equipment of the third party
will be on the same count when leaving the premises. The location of work will be check upon leaving of the third party.”
Name & Signature: Job Designation: Department:

SECURITY

TO BE FILLED OUT BY SERVICING GROUP

PERSON IN CHARGE: “I confirm that the work has been COMPLETED or CANCELLED (encircle whichever is applicable). I have checked the work
CLOSURE/CANCELLATION

and confirm that the work area is left in a safe and tidy condition.”
Name & Signature: Job Designation: Department/Company (if contractor)
Anaclito Macahilig Fireprfessionals(firepro), Inc.
AUTHORIZED PERMIT HOLDER Tech'n
TO BE FILLED OUT BY OPERATIONS/O&M DEPARTMENT
PERSON AUTHORIZING WORK: “I have inspected the work and confirm that it has been COMPLETED or CANCELLED (encircle whichever is
applicable). I confirm that the work area is in a safe and tidy condition.”
Name & Signature: Job Designation: Department:

PERMIT ISSUER

ACTUAL PERMIT CLOSE-OUT DATE & TIME:

Note: Original copy – Control Room; Carbonized Copy – Servicing Group
Oct. 11, 2023 – Activities

10AM to 12NN – Checking the condition of Fire Pump System.

12NN to 1PM – Breaktime (Lunch TIme)

1PM to 5PM – Checking/Inspection Of FDAS System.