Hydrostatic Testing Form-039

Work Permit Rev. AA Date: 02 09 2020

Pressure Testing Water Flushing Water Drainage Others

Section 1 Details of the Permit Receiver

Permit Receiver: Contact Number:

Safety In charge: Contact Number:

Section 2 Permit Validations

Date issued Valid Till (Not more than a day )

Time Issued Valid Till (Expires after 0001 hrs)
HYDRO TEST permit shall not exceed its duration for more than one (1) day.
Work Permit shall be renewed on the Second (2nd) day WITHOUT FAIL

Section 3 Prerequisite (Work May be stopped if one of the following is not complied with)

 for Yes and  for No Yes NA  for Yes and  for No Yes NA
All joints/ Plug / coupling / Flanged are physically G
A Exclusion Zone set up
checked.
Position of Valves – whether Open or closed as per
B H Signage displayed
requirements
Remove /protected all electrical equipments or other Valid Calibration certificates
C I
materials from the place of possible leakages available for Pressure Gauge
D All pipe ends closed by end cap fittings J Close Supervision available

E Are the operatives trained for PRESSURE Testing? K Isolation of Equipments required
Whether Task safety briefing (TSB ) given to
F L LOTO box & Key available
operatives?

Declaration by the Permit Receiver

Company Name:
I______________________________________ hereby
declare that I have checked the location and the employees Nature of Job:
have been briefed about the hazards and emergency procedure Location:
and a toolbox talk given to ALL involved in the activities.
Contact Number (Site Safety Rep)

Date: Signature:

Section 4 Permit Approval

Work shall be carried out ONLY after complying with the precautions given in Section 3 of this Permit.
The permit is valid up to _______ hrs on / / . It has to be ensured that the employee executing the Job has a copy of
the permit at all times during work.

HSE Dept: - Signature Date

Section 5 Permit Closure

Close out by (Receiver): ______________________ Designation _____________________ Signature _____________________

Date & Time ___________________

Closed Permit must be returned to HSE Dept.

Permit Copy Distribution (tick appropriate boxes):

Site Location Supervisor Operatives Health and Safety File
I confirm after thoroughly checking physically in the aforementioned area that proper housekeeping is done, leaving behind the area safe, hence closing this Work Permit.