SAM ENGINEERING / ELECTRO MECHANICS

Permit to Work (PTW)

Requester: Date: Ext.: Dept. /Div. /Group: No.

Brief Description of Work:

Project: Location: Sub-Contractor:

Requester/Designee, Service Provider, and HSE (as necessary) fill out this section or attach analysis
HSE ANALYSIS
Radiation Concerns None Radiography Detail of Source: Min Safe Distance (m):
Safety Concerns None Ergonomics Transport of Hazardous Material
Toxic Materials* Confined Space* Explosives Electrical Excavation
Work At height Corrosive Flammable Magnetic Field* Pressurized Systems

Heat/Cold Stress Noise* Material Handling Rigging/Critical Lift

Fumes/Mist/Dust*
Chemicals* Vacuum Other Please Specify:
Environmental Underground
None Spill potential Soil contamination
Concerns Duct/Piping
Waste-Mixed Air Pollution Water Pollution Other (Please Specify)
FACILITY CONCERNS None
Access/Egress Electrical Noise Potential to Cause a False Alarm Vibrations
Limitations Impacts Facility Use Agreement Temperature Change Other
Configuration Control Maintenance Work on Ventilation Systems Utility Interruptions
WORK CONTROLS
Work Practices
Lock-out/Tag- Security (see
None Exhaust Ventilation Spill Containment
out Instruction Sheet)
Back-up Person/Watch HP Coverage Warning Signs Time Limitation Barricades
Scaffolding-requires
Shade / Heat Control Other
inspection
Protective Equipment
Coveralls Safety Glasses Gloves Safety Shoes Safety Harness
Face Shield Ear Muffs Ear Plugs Respirator Helmet
Other

Training (TRIC) #

ISSUE:
Date / Time Job Supervisor HSE Supervisor Project Manager

Renewal: Cancelation:
Date / Time of issue Job Supervisor HSE Supervisor Time Reason (Please Specify if other)
Shift End

Shift End

Shift End

Shift End

Shift End

Shift End
This Permit is valid for maximum 7 working days only.
All the signatories are responsible for implementing this Permit.
Once this permit is canceled (for any reason), the job shall not be started until the permit is renewed once again.
This permit shall be signed in 2 copies. One will be present at work site and one shall remain with HSE Supervisor for monitoring.
CLOSE OUT:
Date / Time Job Supervisor HSE Advisor Project Manager

If the job is completed, this permit shall be closed out and be kept as a record at site office

IMS-SEEM-F102, Rev.0