Lockout-Tag Out Permit

This Permit is required whenever personnel will work on or near the equipment (electrical, fluid, mechanical or
other) and could be injured as a result of unexpected release of energy or hazardous materials
Project Name: Permit No.

Specific Location of Activity: DATE OF ISSUE:

TIME OF ISSUE:

Work Description: NAME OF CONTRACTOR:

NAME OF RESPONSIBLE SUPERVISOR

SHIFT VALIDITY
Day Night Both
NAME OF AUTHORIZED EMPLOYEE COMPANY TELEPHONE NO. LOCK/TAG NUMBER

TYPE OF EQUIPMENT UNIT NUMBER SPECIFIC LOCATION DURATION (HOURS, DAYS, WEEK)

TYPE OF ENERGY:  Electrical: volts  Pressure: psi Others:

N/
Required Precaution Checklist: Yes No
a
Others
LTP authorized emloyee appointed
Authorized employee familiar with RTCC LTP
Affected employees notification form available
LTP training card available for each authorized employee
Engaged equip. has the ability to accept a lockout devise
Lockout/tagout devices are provided (locks, hasps, tags)
LTP authorization card issued along with lock keys
Authorized employee have complete PPE
Important Notice: By accepting this permit the receiver / undertake to fully comply with the requirements and take full
responsibility of the deviations / non compormance caused by him.
Permit Transfer confirmed by:
EXPIRY DATE: Name of Issuer: Signature: Name:

EXPIRY TIME: Name of Receiver: Signature: Name:

REV-01