Gujeni Integrated Iron Ore Mining and Processing Plants (GIIOMPP),Kagarko LGA, Kaduna State

PERMIT TO WORK
Hot Work Cold Work PERMIT NO.
Copies: Pink – Permit Applicant / Holder, White - Work Site, Green - Authoriser
APPLICATION AND WORK DESCRIPTION (Filled by Applicant):
Planned Work Schedule Date: From ……………………..To ………………………… Time: From …………………………To ….……………………….
Plant: ……………………………………………………………………… Location:…………………………………………………………………………………...
WORK DESCRIPTION: …………………………………………………………………………………………………………………………………………………..
:…………………………………………………………………………………………………………………………………………………

Applicant: Sign:……………………. Name:………………….. Authorisation for shut down: Sign……………………Name:……………………………..

SAFETY MEASURES TAKEN SPECIAL PRECAUTIONS & POTENTIAL

1. REMARKS 2. HAZARDS
BY OPERATIONS FILLED BY APPLICANT / AUTHORISER
Equipment is free from Flammable/ Hydrocarbon/
1.1
Toxic gases
1.2 Equipment properly drained, cleaned
1.3 Water seal has been made
1.4 Bleeders have been opened
1.5 Nitrogen purging has been done
1.6 Radioactive sources protected
1.7
1.8
1.9
2.0
Sign Sign
Name Name
PPE, FIRE PRECAUTIONS, GAS TEST & ASSOCIATED CERTIFICATES To BE FILLED BY PERMIT APPLICANT
3 3A - PPE & OTHERS REMARKS 3B - FIRE PRECAUTIONS & REMARKS 3C - Certificate Nos.
GAS TESTS CERTIFICATES
3.1 Eye, Face & Ear protection Competent Fire Watcher Confined
Space Entry
3.2 Head protection Fire Extinguishers
LOTO Body protection, Full Body
3.3
safety harness Pressure Fire Hose Electrical
3.4 Respiratory protection (BA set) Fire Tender Working at
Height
3.5 Leg protection Screen off Area Excavation
3.6 Portable CO monitor Explosive Test Heavy Lift
3.7 Roof ladder/ Gas cutting sets Carbon Monoxide Test Road Closure
Safe means of access/
3.8 Scaffolding/ Enclosures Oxygen Test Radiography
PERMIT APPLICANT PERMIT HOLDER

_ SIGN: ………………………… NAME: ……………………… SIGN: ………………………… NAME: ………………………

PERMIT AUTHORISER
_ PERMIT VALIDITY Date: From …….….………… To……….. ……….… Time: From ……...………………. To ………………
SIGN: …………………………………………………. NAME: ………………………………………………

4A PERMIT RETURN – WORK COMPLETE 4B PERMIT RETURN – WNC PERMIT CANCELLATION

Permit Return by Permit Holder: Work Complete. 5.1 Permit Return by Permit Holder: Work Not Complete (WNC).
Work Site &Equipment affected Left in safe condition Work Site &Equipment affected Left in safe condition
4.1
Sign:………………………… Name:……………………… Sign:…………………………… …….. Name:………………………… ………..
Date: ……………………… Time: ……………………… Date: ………………………………….. Time: ……………………………………..
Permit return by Applicant 5.2 Permit return by Applicant
4.2 Sign:………………………… Name:……………………… Sign:…………………………… …….. Name:………………………… ………..
Date: ……………………… Time: ……………………… Date: ………………………………….. Time: ……………………………………..
Permit accepted by Authoriser Permit accepted by Authoriser
Sign:………………………… Name:……………………… 5.3 Sign:…………………………… …….. Name:………………………… ………..
4.3
Date: ……………………… Time: ……………………… Date: ………………………………….. Time: ……………………………………..

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 PERMIT RE-VALIDATION:

PERMIT APPLICANT PERMIT HOLDER

SIGN: ………………………… NAME: ……………………… SIGN: ………………………… NAME: ………………………

PERMIT AUTHORISER
PERMIT VALIDITY Date: From …….….………… To……….. ……….… Time: From ……...………………. To ………………
SIGN: …………………………………………………. NAME: ………………………………………………
Heavy
CERTIFICATES Working at height Confined space Electrical LOTO
lift
Tick mark Radiography Excavation Road closure

PERMIT APPLICANT PERMIT HOLDER

SIGN: ………………………… NAME: ……………………… SIGN: ………………………… NAME: ………………………

PERMIT AUTHORISER
PERMIT VALIDITY Date: From …….….………… To……….. ……….… Time: From ……...………………. To ………………
SIGN: …………………………………………………. NAME: ………………………………………………
Heavy
Working at height Confined space Electrical LOTO
CERTIFICATES lift
Tick mark Radiography Excavation Road closure

EXTENSION FOR ROAD CLOSURE

APPLICANT HOLDER AUTHORISER
DATE
SIGN NAME SIGN NAME SIGN NAME

SAFE LIMIT OF GASES/ VAPOURS

SAFE CONCENTRATION FLAMMABLE LIMITS
GAS FOR
LOWER UPPER
8 HRS DURATION

CARBON MOMOXIDE 50 PPM 12.5 % 74.2 %

HYDROGEN - 4.0 % 75 %
L PG 1000 PPM 2.2 % 9.9 %
AMMONIA 25 PPM 16% 23%
Chlorine 1 PPM - -

IMPORTANT INSTRUCTIONS:
1. Permit is valid for one shift, and it can be extended for two shifts (Permit Validity 24 hrs Max) except for Road Closure which valid for a period of seven days
and it is to signed by Authorizer for every 24 hrs.
2. Permit is not valid in the event, if conditions in the incident area become Hazardous from conditions not existing when this permit was issued/ or in the event
of any Emergency/ Fire.
3. The authorized person should issue permit only.
4. Work Instructions & Protocol procedures are to be strictly followed.
5. If job is not completed within the validity time period, the authorized person incorporating necessary changes must extend the permit.
6. Permit must be returned by the applicant to the issuing authority after completion of the job.
7. When more than one agency is working at a place the concerned agencies must co-ordinate among themselves for safety of the persons working there.
8. No job should be attempted / to be done for which permit is not issued.
9. Workers must be briefed about imminent dangers involved in the job.
10. Persons working at height and Confined Space should be medically checked for acrophobia and claustrophobia respectively.
11. Separate Certificates are to be taken for the jobs involving Excavation, Confined Space Entry, Working at Height, Radiography, Electrical, LOTO,
Road Closure & Heavy Lift jobs.
12. Results for the Confined Space Entry to be periodically recorded on the Certificate.
NOTE: If the Applicant does not fill it, Authoriser can fill it up if necessary or write “NIL”.

BEFORE AUTHORISING THE PERMIT

ENSURE THAT SITE IS SAFE TO WORK & SAFE WORKING CONDITIONS ARE MAINTAINED

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 Confined Space Entry Certificate

THIS IS NOT A PERMIT TO WORK

CONFINED SPACE ENTRY CERTIFICATE Certificate No.

Yellow - Permit Applicant / Holder, Green-Work Site, Blue-Authorizer
1. APPLIED BY PERMIT APPLICANT (To be filled by Applicant)

Sign: Plant: Permit No:

Name: Confined Space Identification No :

Date: Location Of Confined Space:

Description of Confined Space: Work Description: Equipments/Tools/Chemicals used

for this work:

2. TYPE OF HAZARDOUS WORK

Combustion Hazards Spark Producing

Welding Chipping Electrical

Burning Grinding Rotating space

Open flame Drilling Task-generated

Other Hazards

❑ Toxic material ❑ Spilled material ❑ Adjacent processes ❑ Working on unguarded

equipment
❑ Corrosive material ❑ Flammable material ❑ Hot equipment or ❑ Other
process

❑ Biological agents ❑ Electrical close ❑ Radioactivity

clearance

❑ Chemical and jet ❑ Fall prevention ❑ Tightening joints

cleaning under pressure

❑ Disconnect and blank ❑ Hazardous materials ❑ Welding fumes and

from drains, sumps heat

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3. SAFETY PREPARATIONS

Personal Safety Space Preparation Equipment Cleaning and

Draining
❑ Protect against by ❑ Isolate ❑ Steam

❑ Fresh air blower ❑ Rubber boots ❑ Lockout/tag out ❑ Fill and drain

❑ Fresh air mask ❑ Ear protection ❑ Disconnect and blank ❑ Remove deposits

❑ Escape air pack ❑ Other barrier clothing ❑ Post work signs ❑ Visual inspection

❑ Dust respirator ❑ Evacuation instructions ❑ Rope off work area ❑ Neutralize contents

❑ Coveralls ❑ Two escape routes ❑ Erect barricade

❑ Safety shower ❑ Life-line harness ❑ Block roadway Fire Safety

❑ Acid suit ❑ Life-line belt/wristlets ❑ Protect against ❑ Specify fire watch in

external hazards "Remarks"

❑ Acid hood ❑ Chemically resistant ❑ Area alarm no.

lifeline

❑ Face shield ❑ Fire alarm box Electrical Precautions ❑ Fire hose laid out

❑ Chemical goggles ❑ Escape ladders ❑ Lock out circuits ❑ Water hose running

❑ Rubber gloves ❑ Mechanical extraction ❑ Pull fuses ❑ Keep area wet

device

Communications: ❑ Telephone ❑ Spark containers and ❑ Cover sewer openings

❑ Radio ❑ Other shields

❑ Location/type of additional assistance (third ❑ Welding-arc ❑ CO2 extinguisher

alternate) protection

Remarks ❑ Ground fault ❑ Dry powder extinguisher

interruption
❑ Proper grounding ❑ Other

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5. CHECK LIST Items to be checked by Area In charge before confined space entry
can proceed
Required
Yes No NA
1. a. The above equipment has been isolated from all sources of dangerous liquid,
gases and fumes by insertion of spades or by removing a section of pipe work and
blanking open end of the circuit

b. Equipment has been isolated from all sources of electrical and mechanical power

2. Equipment free of all dangerous materials. All flushing /inert gas purging completes,
all liquid drained and ventilation atmosphere restored on confined space

3. Equipment surrounding area checked and safe from hazard arising from other
work /operation

4. Lifeline, breathing apparatus and resuscitation equipment available

5. Adequate access and escape routes are provided

6. Fresh air supply equipment installed and operational. v e s s e l sufficiently cooled for access

7. Procedure and rescue plans formulated and discussed with permit holder, personnel
entering vessel and stand by personal. vacation exercise conducted where stated as
required on permit

8. Stand by personal appointed

9. Fire Extinguishers / Fire Hydrant line available?

10. All persons engaged for working provided required training?

Name of the Area In charge Signature

Date Time

6. GAS TESTING

RESULT OF TEST GAS LIMIT RESULTS

OXYGEN 19-21 % VOL %
HYDROCRABONS 0% LEL for Hot work %
CO 50 PPM (0.005%) PPM
NH3 <15 PPM PPM
TEMPERATURE ⁰
DUST 10 mg/Cu.M C
mg/Cu.M
Any other Fumes
Confined Space Tested

I have tested this space for the above gases, with the results shown

Name Signature Date Time

GAS TESTER

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7. TEST HAVE BEEN CARRIED OUT IN THE ABOVE MENTIONED CONFINED SPACE AND ENTRY IS PERMITTED AS
INDICATED BELOW;

Recommendation for Periodic Checking

(Subsequent gas testing reports shall be recorded)

Entry into the confined space is permitted With / Without Breathing Apparatus.

From Date Time .

Until Date Time

Entry wearing Breathing Apparatus subject to the following conditions

i. An observer must be positioned outside the confined space.

ii. Where practicable, each man is wearing belt or harness with life line attached and that the observer
positioned outside is holding the free end of the life line and is capable of pulling out the men.

8. PERMIT APPLICANT AND PERMIT HOLDER 9. PERMIT AUTHORISER

I understand all the above safety precautions. I will ensure I certify that the above results indicate that the
that work only take place when all these safety precautions confined space covered by this certificate is
are complied with. safe to enter.
PERMIT APPLICANT PERMIT HOLDER

Sign : Sign : Sign : Date :

Name: Name:
Name: Time :
Date : Date :

Time : Time :

RETURN OF ‘PERMIT TO WORK’ AFTER JOB COMPLETION

The work planned inside the confined space is completed / incomplete / not taken up. The confined space and the
equipment therein are left in safe condition. The permit to work Permit No: issued based on this
certificate shall be closed.
PERMIT APPLICANT PERMIT HOLDER

Sign: Sign:

Name: Name:

Date & Time: Date & Time :

This Certificate for Confined Space Entry is cancelled

Sign of the Authoriser : Date & Time :

Name of the Authoriser:

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 Confined-space Entry Log & Subsequent Gas Test Records

Confined Space Identification Number : Unit/Location :

Date:

All entrants and attendants have been instructed about potential hazards, safety precautions, and
specified protective emergency equipment.
1. Confined-Space Entry Log
Time
Name (all persons entering or attending) Time in Initials Initials
out

2. Subsequent Gas Test Record

DATE TIME RESULTS OF GAS TETS SIGNATURE OF
CO O2 NH3 HYDROCRABON GAS TESTER

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 Confined-space Rescue Plan

(This must be attached to the Confined Space Certificate)

Date: – Time: -

Emergency telephone numbers:

Exact Location of the Entry:

How will the Emergency Response Team be summoned?

Method of rescue:

Rescue Equipment Required for Safe Rescue:

Will the rescue equipment be located at the point of the rescue? Yes No

If no, where will the rescue equipment be located?

Describe any likely hazards the rescue team may face and how they will be controlled?

Signature of person approving initial rescue plan

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 WORKING AT HEIGHT CERTIFICATE
THIS IS NOT A PERMIT TO WORK

Yellow - Permit Applicant / Holder, Green-Work Site, Blue-Authorizer

Permit No.
Section: 1 To be filled in by Permit Applicant
Date of Issue
Permit Valid From …………….…….. To ………………..………………………………...,
If Permit Applicant / Holder changed then their Name & signature should be incorporated in
the format
Applicant's Name Sign Dept

Location
Description of work

Action Taken by Permit Holder: Please tick the relevant action taken in the box provided.
Sr.No Safety Checks for compliance Yes No NA
1 Risk Assessment has been carried out for the job & attached with this permit (MANDATORY REQUIREMENT)
2 Contractor & their workmen have been fully briefed about the risk associated to the job.
3 Whether safe access to workplace is provided
4 Work platforms provided with guard rails
5 Adequate fall protection arrangement made (Double Lanyard Harness, Fall arrestor, Lifeline, Safety Net)
6 Are the workmen are medically fit for working at height job
7 Is the work area away from the vicinity of moving objects
8 Protection against objects falling from above height
9 Whether area below, where the height work being performed is cordoned & unauthorised entries are
restricted
10 Work at more than one elevation at the same segment is restricted
11 Other specified precautions
Name of Permit Authoriser Department Signature Date Time

Section-2 : Acceptance (Permit Holder)

I understand the work which is to be carried out and the method of work to Name: Date & Time
be used to ensure that it is carried out safely. Signature:
No work will be carried out other than the work authorised by this permit
Extension / Transfer of permit All checks reviewed & found OK to extend permit Remarks
Date Time Permit Holder Permit Applicant Permit Authoriser
Signature Signature Signature
From To

Section-3 : Completion To be completed by the Permit Holder after completion of the work & handed over to
(Permit Holder) Permit Applicant / Authorizer
Permit Holder Signature
Date & Time
Section-4: Cancellation: I declare that this permit is now cancelled. No further work at height is allowed until a new permit is issued

Permit Applicant Permit Date Time Remarks

Authoriser

Note : 1. This permit Applies only to work in the location described. Any further height work must have another permit
issued for prescribed validity
2. This permit only applies to the person to whom it is issued. If work has to be continued by someone else, this
permit must be returned to issuer for cancellation and another permit issued.

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 LOCK OUT TAG OUT CERTIFICATE

Yellow - Permit Applicant / Holder, Green-Work Site, Blue -Authorizer

THIS IS NOT A PERMIT TO WORK
1. APPLIED BY PERMIT APPLICANT (Application has to take the clearance from all the concerned dept)

Sign………………………………………… Plant………………………………………………
Certificate No…………..
Name……………………………………… Location………………………………………...

Date………………………………………… Equipment to be
isolated…………………………………………. Permit No………………….

2. ELECTRICAL ISOLATION
Controls Padlock No. Tagged (Yes /No) Remarks
2.1 Switched Off
2.2 Main Fuses removed
2.3 Control Fuses
2.4 Padlocking
2.5 Breakers
2.6 Others Precautions..
2.7
2.8
2.9
2.10
2.11
2.12

I hereby confirm that above isolation and precautions have been taken, the equipment has been proven
isolated by test and all concerned/ affected individuals has been adequately informed.

Name of the Authorized person

Performed Isolation Name……........................ Sign………………………………..

Date………………….. ………… Time………………………………..

3.0 RECEIPT OF CERTIFICATE BY PERSON
INCHARGE OF WORK. Name……........................ Sign………………………………..

Date………………….. ………… Time………………………………..

4.0 MECHANICAL ISOLATIONS

Controls (Mechanical, Padlock No. Tagged (Y/N) Remarks

Pneumatic, Hydraulic, etc,)
4.1
4.2
4.3

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4.4
4.5
4.6
4.7
4.8
4.9
4.10
I hereby confirm that above isolation and precautions have been taken, the equipment has been proven
isolated by test and all concerned/ affected individuals has been adequately informed.
Name of the Authorized person
Performed Isolation Name……........................ Sign………………………………..

Date………………….. ………… Time………………………………..

5.0 RECEIPT OF CERTIFICATE BY PERSON
INCHARGE OF WORK. Name……........................ Sign………………………………..

Date………………….. ………… Time………………………………..

6.0 COMPLETION OF WORK

I hereby confirm that the task detailed in section 1 above is completed, the personnel and equipment
withdrawn and the isolation may now be removed by a competent person.

Applicant: Name : --------------------- Sign………………………Date………………. Time…………………..

7.0 CONFIRMATION OF DE-ISOLATION
I hereby confirm that the isolation detailed in section 2/4 has been removed and the system
energized.

a. Authorized person Sign………………. Date…………………….. Time……………………

b. Authorized person Sign………………. Date…………………….. Time……………………..

Note: Authorized Person is either Mechanical / Electrical or both

8.0 LONG TERM ISOLATION
I hereby confirm that the task detailed in section 1 above is not completed and the equipment has
been entered as a “Long Term Isolation”, I have placed the equipment isolation keys and a copy of this
certificate in the “ Long Term Isolation Box” ,

a. Permit Applicant: Sign………………………… Date …………………. …. Time………………………

b. Area Authorizer : Sign…..…………………… Date ………………. Time………..

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 ELECTRICAL CERTIFICATE
THIS IS NOT A PERMIT TO WORK

Yellow - Permit Applicant / Holder, Green-Work Site, Blue-Authorizer

Hot work / Cold Work permit - Permit no. _ _ Certificate No:

A) Plant/Area: Equipment Tag No. : _ _

Location of the job : _ _ _
Details of the job : _ _ _ _
_ _ _
Name of the contractor : No. of Workers :
B) Clearance by Operations
Clearance from operations dept. is hereby granted for carrying out the above job.
Name Signature Date Time

C) Precautions taken( Tick mark which are applicable, strike out whichever not applicable )

Normal supply Alternative supply _ Earth continuity checked

_ _ Switches put ' Off ' _ Use electrical gloves rated 11/33 KV.
_ _ Power fuse remove _ Other? _ _
_ _ Control/space heater fuses removed
_ _ Breaker racked out
_ _ Do Not Operate tags provided, Tag No.
_ _ Terminal / Cable earthed and short circuited.
D) Special instructions :
_ _ _
_ _ _
E) Applicant & Authorizer : Certify that the precautions are fulfilled and work site plus equipment are ready and safe
for the job
Permit is valid upto hrs. on _ unless extended as per section F.

Designation Name Signature Date Time

Applicant Certified Electrical Person

Authoriser Certified Electrical Person

Holder Certified Electrical Person

F) Extension of Validity (to be renewed every shift - max. validity - 24 Hrs.)

Conditions checked and the permit is re-validated as under :

Applicant Authorised by Extended up to

Name Signature Name Signature Date Time

Extension 1

Extension 2
G) Job completion and closure of certificate: Job is completed and we have inspected the site & found the area
cleared of men and materials. Temporary earths also removed.
Certificate is hereby closed.
Name Signature Date Time
Authoriser
Applicant
Holder

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 HEAVY LIFT CERTIFICATE
Yellow - Permit Holder, Green-Work Site, Blue-Authorizer

Permit No……………………………………….. Certificate No………………………………………

Location Date Time
THIS IS NOT PERMIT TO WORK
Lift Information
Description of Load :
Weight of load
Dimensions
Equipment & Load information
Crane
Type
Model
Competent Person Test Certificate Validity
Crane Information
A. Maximum Operating Radius
B. Main boom length
C. Jib length
D. Jib Offset
E. Attachments (Luffing jib, Super lift)
F. Counterweights required
G. Vertical Clearance between boom Hook & load
Competency of Crane Operator ( Mention the Details )
Driving License :

Medical Fitness :

Certified ( OEM ) Training :

Crane operator Name: Sign:

Site Conditions
H. Obstructions
I. Distance from power lines
J. Ground Stability
K. Underground utilities
L. Wooden Stoppers or mats needed ?
Calculations
M. Lifting Capacity
N. Weight of load
O. Total weight of accessories
P. Total weight of lift (N + O)

*Authorised Engineer Name:. Signed:

*Authorised engineer must undergo Permit to Work, Lock Out and Tag Out, Working at Height, C o n f i n e d Space Entry
Trainings

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 EXCAVATION CERTIFICATE
Yellow - Permit Applicant / Holder, Green-Work Site, Blue-Authorizer

THIS IS NOT A PERMIT TO WORK

1. APPLIED BY PERMIT APPLICANT (Applicant to get clearance from all concerned dept.)

Sign………………………………………… Plant………………………………………… Certificate No………….

Name……………………………………… Location……………………………………
Permit No……………..
Date………………………………………… Equipment………………………………….
2. DETAILS OF EXCAVATION Limits of excavation to be shown on as built drawing attached to this certificate

3. DETAILS OF EXISTING UNDERGROUND SERVICES NEAR EXCAVATION

4. DEPARTMENT APPROVAL (Department to be consulted to be specified by responsible Executive)

I have examined the drawings of the proposed excavation, and of adjacent underground services, I confirm that the
excavation may proceed, subject to any comments noted below.

DEAPARTMENT REMARKS /CONDITION/ OBSERVATION SIGNATURE NAME DATE

TELECOM
ELECTRICAL/
INSTRUMENT
CIVIL
UTILITIES
OTHERS

5. PRECAUTIONS
5.1 Cable detector to be used over proposed route
5.2 Pilot Trenches to be hand dug to locate services.
5.3 Excavation may be carried out by mechanical
means of after pilot trenches are completed,
but no closer than 1 mtr of service.
6. PERMIT AUTHORISER 7. PERMIT HOLDER

I Authorize the excavation work specified above to be carried I understand all the above safety precautions; I will
out, subject to the nominated safety precaution and ensure that work only takes place when all these
conditions being maintained during the validity period of the safety precautions are complied with.
permit(s) to work specified in the certificate

Sign:………………,,,… Name:…………………………
Sign:………………,,,… Name:…………………………
Date: ………………… Time:…………………………
Date: ………………… . Time:…………………………

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 CERTIFICATE FOR CLOSURE OF ROADS
Yellow - Permit Applicant / Holder, Green-Work Site, Blue -Authorizer

Permit No: CERTIFIFCATE No.

A) Plant/Area: Equipment Tag No. :

Location of the job:.
Description of the job / reason for closure :

Name of the contractor : No. of Workers :

B) Precautions Taken ( Tick mark which are applicable, strike out which are not applicable )
Alternate route for the traffic arranged , Please specify

Temporarily barricade using caution tapes.

Physically barricade using pipes/rods

Warning signs installed at 50M, 100M & 150 M (road diversion, men at work, night lamp, etc.)
C) Clearances by other departments
1. Fire department 2. Security department
Alternate route indicated is Alternate route indicated is

Okay Not okay okay Not okay

If not ok, suggestion for alternate route : If not ok, suggestion for alternate route :
-------------------------------------------------------- -------------------------------------------------------

Name Signature Date Time

Fire Dept
Security Dept
D ) Additional precautions / special instructions :

E) Authoriser and Applicant : Certify that the precautions are fulfilled, work site, equipment are ready
and safe for the job. Permit is valid upto hrs. on unless extended as per section F.

Designation Name Signature Date Time

Applicant
Authorized by
Permit Holder

F) Extension of Validity (to be renewed every day. Max. Validity - 7 days).

Conditions checked and the permit is re-validated as under :
Extended by Applicant Accepted by Authorizer Extended up to
Name Signature Name Signature Date Time
Extension 1
Extension 2
Extension 3
Extension 4
Extension 5
Extension 6
G) Job completion and closure of permit: Job is completed and we have inspected the site and found the
Area cleared of men and materials. Permit is hereby closed.
Name Signature Date Time
Applicant
Authoriser
Permit Holder

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 RADIOGRAPHY CERTIFICATE
Yellow-Radiological Officer, Green-Work Site Blue-Authorizer Copy

THIS IS NOT PERMIT TO WORK

1. APPLIED BY PERMIT APPLICANT

Sign………………………………………… Plant………………………………………… Certificate No………….

Name……………………………………… Location………………………………………
Permit No……………..
Date………………………………………… ………………………………………
2. REASON FOR RADIOGRAPHY

A. GENERAL INFORMATION:
RADIATION SOURCE :

1. X-RAY APPARATUS : MAKE _

TYPE

MAX.TUBE VOLTAGE _KV

2. RADIOACTIVE SUBSTANCE SEALED UNSEALED

TOTAL ACTIVITY HALF LIFE_

ISOTOPE

TYPE OF RADIATION BETA GAMMA NEUTRON

ALPHA

B. SPECIAL PRECAUTION TO BE TAKEN:

_
_
4. PERMIT HOLDER (Qualified Radiation
3. PERMIT AUTHORISER
Protection Supervisor)
I Authorize the radiography test specified above to be I understand all the above safety precautions; I will ensure
carried out, subject to the nominated safety precaution that work only takes place when all these safety precautions
and conditions being maintained during the validity are complied with.
period of the permit(s) to work specified in the certificate Note: Part A & B to be filled by Radiation Protection
Supervisor only.
Sign:………………,,,… Name:………………………… Sign:………………,,,… Name:…………………………
Date: ………………… . Time:………………………… Date: ………………… Time:…………………………

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