COLD WORK PERMIT BASF PETRONAS Chemicals Sdn Bhd Assembly point no.

: ____________________________________________ ☒ NA
Hazard Assessment and Protective Measures Measure Implemented Measure Normalized
ORIGINAL (Receiving Party) CW NNNNN Yes No
Check boxes using “x” only (Name, Date & Sign.) (Name, Date & Sign.)
A - General information 5 Additional organisational measures:
☐ New ☐ Continuation from no. CW: ___________ Dept. / Company Name Contact No 5.1 Identification of the plant component before removal / line cutting ☒ ☐
1. Permit Issuing Supervisor Atlas copco (M) Kuilan A/L Gengan 0193466047 5.2 Other: _______________________________________________________ ☐ ☐
2. Receiving Authority 6 Other units affected: ☐ Yes ☐ No
3. Job Coordinator required? ☒ Yes ☐ No Unit/Dept. Responsible Person Safety Measures  Date/Sign.
6.1 Mr.Ahmad Shauqi Safuan
B - Work description
6.2
1. Equipment tag / Name: Air Compressor Specific Location: Comp.Room
2. Proposed Work (to specify clearly): Service job E - Protective measures during work
Yes No Yes No
1 Personal Protective Equipment 1.10 Fall protection gear, type: ☐ ☒
3. MOC Related: ☐ Yes ☒ No (if tick Yes, MOC No: ____________________________________) 1.1 PPE required for a limited time only ☒ ☐ ☐ Safety harness ☐ ______________________
4. Override or Bypass Permit related: ☐ Yes ☒ No (if tick Yes, Ref No: ______________________) During: ____Working___________________; Refer Line: 1.11 Other: ____________________________________ ☐ ☒
5. Line cutting (tagging no.): __________________________________________________________ ________
6. Valid on Date (date of section H approval): Time from (use 24hr clock): Time to (use 24hr clock): 1.2 ☒ Safety glass ☒ Safety helmet ☒ Safety shoe ☒ ☐ 2 Continuous Supervision (if required)
7. Extension Date: (valid until 7 consecutive days from B6. Valid on Date) 1.3 ☐ Safety goggle ☐ Face shield ☐ ☒ 2.1 Supervision by (Name & Sign.): ☒ ☐
1 2 3 4 5 1.4 Protective gloves, type: _____Cotton ☒ ☐
glove________________________
1.5 Rubber safety boots ☒ ☐ __________________________________________
C – Hazard Identification 1.6 Apron, type: ______________________________________ ☐ ☐ 3 Ventilation Measures
Substance during normal operation: ___________________________________ Flushing / Washing / Rinsing medium during work: ___________________________ 1.7 Protective suit, type: ________________________________ ☐ ☐ 3.1 Ventilation type:  Forced Natural ☒ ☐
1.8 Respiratory protection device, type: ____________________ ☐ ☐ 4 Other measures
1.9 Hearing protection: ☒ Ear plug ☒ Ear muff ☒ ☐ 4.1 __________________________________________ ☐ ☐
! If anything unexpected happens, stop work immediately and notify Permit Issuing Supervisor
Toxic Explosive Flammable Corrosive Liquified Gas Oxidizing
Specific Target Dangerous to Irritant / Harmful F - Post work protective measures
Organ Environment Yes No
☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ 1. Leak test with medium: _______________________________________________________________________________________________ x 
The Proposed Work require protection against hazardous substances: ☐ Yes ☐ No (if No, specify reason: _____________________________________________) 2. All tools and work equipment to be removed and area cleaned to original state (housekeeping) x 
☐ Hazard due to flushing medium, during work: ______________________________________________________________________________________________________ 3. Report status of work to D6.1, D6.2 by: ________________________________________________________  Daily  Work completion x 
☐ Product residue may be present: __________________________________________________________________________________________________________ 4. Other: _____________________________________________________________________________________________________________  
☐ Hazardous reaction upon contact with water ☐ Hazardous reaction upon contact with organic substances (e.g. Oil) G - Verification of hazard assessment and approval of protective measures listed in sections C, D, E, F
☐ Height ☐ Sharp edge ☒ Dust ☒ Noise ☒ High temperature
_____________Kuilan.g________________________________________________ ________________Mr.Ahmad_Shauqi
☐ Trap pressure ☐ Hot surface ☒ Cold surface ☐ Voltage ☐ Moving parts _____ Safuan_______________________________________________
☐ Pinch point ☐ Tripping ☐ Slippery ☐ Radiation exposure ☐ Heat stress 1. Name / Date / Signature of Permit Issuing Supervisor – A1 2. Name / Date / Signature of Approving Authority
☐ Other hazards: ________________________________________________________________________________________________________________________ H - Approval for work to be undertaken (Measures as per D implemented & physically checked)
____________________________ ; __________________________; ____________________________; _________________________; I / We confirmed that I / We had briefed and informed the Receiving Authority for acceptance.
☐ Hazard in accordance with permit No:
____________________________ ; __________________________; ____________________________; _________________________;
__________________________________________________________________ ________________________________________________________________
D - Pre-work protective measures
1. Name / Date / Signature of Permit Issuing Supervisor – A1 2. Name / Date / Signature of Job Coordinator – A3
Yes No Measure Implemented Measure Normalized
I - Acceptance of permit to conduct work as per B2
(Name, Date & Sign.) (Name, Date & Sign.)
I have been briefed, understood and shall comply with all requirements. I shall brief all working employees prior to start work and attached the On-Site Safety Briefing
1 Isolation list available. ☐ ☒
attendance forms.
Isolation Document No: _________________________________________
1.1 Isolation list attached (mandatory for blinding / de-blinding PTW) ☐ ☐
________Kuilan.g__________________________________________________________
1.2 Personnel Padlock no: __________________________________ ☐ ☐
1. Name / Date / Signature of Receiving Authority – A2
2 Making plant equipment safe:
2.1 Depressurize ☒ ☐ NA J1 - Interim energization of E&I for test purposes Not Applicable J2 - System de-energized again
2.2 Moving parts secured with: ___________pallet ☒ ☐
jack____________________________
___________________________________________ ______________________________________ _________________________________
2.3 Other: _______________________________________________________ ☐ ☒ 1. Name / Date / Time / Signature of Receiving 2. Name / Date / Time / Signature of Permit Issuing 1. Name / Date / Time / Signature of Chargeman /
3 Draining/cleaning of process equipment: Authority – A2) Supervisor – A1 Radiation Protection Supervisor (RPO)
3.1 Drain ☒ ☐ NA K - Confirmation of post work protective measures as per “F” and proposed work as per “B2” has been completed
3.2 Purge with: ___________________________________________________ ☐ ☒ NA The protective measures listed in “Section F” have been completed successfully: ☒ Yes ☐ No
4 Making the work location safe: The proposed work listed in “Section B2” has been completed successfully: ☒ Yes ☐ No
4.1 Barricade with: ________________________________________________ ☒ ☐
4.2 Container for bolts and nuts ☒ ☒
4.3 Covering for pipes, equipment, electrical cables, grates, drains, pit, shafts, wall ☐ ☒ _______________Kuilan.g___________________________________________________
and traffic routes in vicinity and below 1. Name / Date / Signature of Receiving Authority – A3 2
4.4 Leak / Gas test if required. Reading: _______________________________ ☐ ☒ NA L – Approval for normalizing of protective measures under section D and permit closure
4.5 Job Safety Analysis(JSA) / procedure required and attached ☒ ☐ NA Other permits using protective measures listed in Section D: ____________________________; ______________________________; __________________________
4.6 Emergency measures: Job completed? ☐ Yes ☐ No (if “No”, continue with No. CW: _______________________________________)
Nearest Safety Shower available ☒ ☒ NA Did normalization of protective measures are required? ☐ Yes ☐ No (if “No”, Reason: _______________________________________________________________)
Escape Route communicated ☒ NA

1|P a g e Cold Work Permit / Issue Jul 2019

__________________________________________________________ Name / Date / Signature of Permit Issuing Supervisor – A1

Cold Work Permit Extension

Extension Number:
Date (dd/mm/yyyy):
Time From (use 24hr clock):
Time To (use 24hr clock):
☒ The Scope of Work (B), Hazards (C) and Protective
Measures (D, E & F) unchanged?
[G1: Permit Issuing Supervisor]
☒ Protective measures according to D verified and
approved again?
[H1: Permit issuing Supervisor]
☐ Hazard in accordance with other permit no. (Section
C): [G1: Permit Issuing Supervisor]
☐ Responsible Person for other units affected notified?
D 6.1
D 6.2
☒ Permit Issuing Supervisor [A1]
☒ Receiving Authority [A2]
☐ Job Coordinator [A3]
☐ Continuous Supervision by as per [E2.1]
☐ J1 Interim Energization:
Receiving Authority [A2]
Permit Issuing Supervisor [A1]
☐ J2 System de-energized again by Chargeman /
Radiation Protection Supervisor
1 2 3 4 5
/ / / / / / / / / /
: : : :
: : : :
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
_______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.

Change of Personnel – this table to be filled if there is change of personnel within shift (Permit Issuing Supervisor is to notify all persons involved with the work of the change in personnel)
Change Number: 1 2 3 4 5
Date (dd/mm/yyyy): / / / / / / / / / /
Time of change (use 24hr clock) : : : : : :
From : From : From : From : From :
Change of Permit Issuing Supervisor [A1]
To: To : To: To: To:
From : From : From : From : From :
Change of Receiving Authority [A2]
To: To: To: To: To:
From : From : From : From : From :
Change of Job Coordinator [A3]
To: To: To: To: To:
From : From : From : From : From :
Change of Continuous Supervision by as per [E2.1]
To: To: To: To: To:
Approval by Permit Issuing Supervisor [A1]
(If the change is a change of Permit Issuing Supervisor, the new _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________
Permit Issuing Supervisor will sign here) Name & Sign. Name & Sign. Name & Sign. Name & Sign. Name & Sign.
NOTES
1. This permit expires upon: (i) as specified above, (ii) any incident, (ii) activation of emergency alarm or (iv) 7 consecutive days after start date of H.
2. In case of (i) any incident (ii) any conditions not fulfilled under D, E & F or (iii) any change in work condition, immediately stops work and notify the Permit Issuing Supervisor.

2|P a g e Cold Work Permit / Issue Jul 2019

 3. The original copy of this permit shall be visibly displayed all the times at the work place.
4. PTW shall be returned to the Permit Issuing Supervisor or his designated person at the end of the validity period.

3|P a g e Cold Work Permit / Issue Jul 2019