Work Permit Form

 

 

BANYU URIP PROJECT INFRASTRUCTURE FACILITIES EPC - 5

WORK PERMIT SYSTEM Doc No. IDBC-RH-SPZZZ-C00008

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Health Safety Environment

Surat Izin Kerja Pekerjaan Panas

1. Description/location

Cold Work

Energy Isolation

Pekerjaan Dingin

Facility / Fasilitas

:  : 

No. of Work Permit

:

Date / Tanggal

PERMIT TO WORK Hot Work

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Excavation Penggalian

Critical Lift Pengangkatan Kritis

Confined Space Bekerja Diruang Terbatas

Isolasi Energi

of job / Uraian / Lokasi Pekerjaan

................................................ ................................ ................................ ............................... ................................ ................................. ............................. ............. .......................................................................................................... ................................... ............... .................................... ............................... ............................... ................................. ............................... ............................... ................................. .................... .... ................................................................................. ................................ ............... ...................................... ................................... ............................... ................................. ................................ ............................... ................................ ................................. ........................... ........... ........................................................

2. Validity of Work Permit / Masa berlaku Izin kerja

No. of Worker / Jumlah Pekerja Work Permit Applicant / Pemohon

Date / Tanggal : From …………….....Hrs  To..................... .......................... ..... Hrs Sign / Tanda tangan

Work Permit Holder / Pemegang Izin Kerja Authorized Person / Penanggung Jawab Check if applicable and explain below    Mechanical Electrical 3. Isolations / Isolasi Jika ada mohon dijelaskan dibawah ini ………………………………………………………………………………………………………………………………………………………   ………………………………………………………………………………………………………………………………………………………   Time and date isolated / Jam dan Tanggal Isolasi:

Isolated by / Diisolasi Oleh:

Position / Jabatan :

………………………… 

…………………………………..  

………………………… 

4. Work Permit Requirement / Persyaratan Izin Kerja

JSA & Risk Assessment

Drawing Activity

Rigging Plan

Work Method

As build Drawing

Underground Composite

prec autions / Beri tanda pada (Check the hazards and the required precautions pada baha bahaya ya dan  pencegahannya  pencega hannya))

5. Hazards Liquid/ gas under pressure / Cairan Gas bertekanan Explosion due to combustibles co mbustibles / Ledakan dari material yang mudah terbakar 3rd party operations (explain below) /  Aktifitas Kontraktor Kontraktor (Jela (Jelaskan skan dibaw dibawah) ah) Noise / Kebisingan

Confined spaces / Didalam Ruang Terbatas Danger of falling / Bahaya Jatuh Moving machinery / Peralatan / Mesin yang  bergerak  bergera k Flying particles or sparks / Partikel terbang/Percikan api

Weather / Cuaca Electricity/ Kelistrikan Corrosives / Korosi Pinch points / Terjepit

Fire / Kebakaran Toxins / Keracunan Lifting Ops. / Pengangkatan Scaffolding / Perancah

Other Hazards / Bahaya Lainnya ………………………………………………………………………………………………………………………………………………………   ………………………………………………………………………………………………………………………………………………………  

Precautions:

Fire Extinguishers / APAR

   Airline (cascade)

    Water flushing

   Supervision

   Grounding

Inert purging

Stand-by-man

Ventilation

PPE

H2S Monitoring

Safety harness

SCBA

Barriers

Job Safety Analysis (JSA) Other precautions / Pencegahan lainnya :

 

 

BANYU URIP PROJECT INFRASTRUCTURE FACILITIES EPC - 5

WORK PERMIT SYSTEM Doc No. IDBC-RH-SPZZZ-C00008

REV. 0

Health Safety Environment

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………………………………………………………………………………………………………………………………………………………   ………………………………………………………………………………………………………………………………………………………  

6. Gas Testing / Pengetesan Gas Oxygen / Oksigen Date Tanggal

Time Jam

Flammable Gas / Gas mudah terbakar

H2S Reading Hasil

Date Tanggal

Time Jam

Reading Hasil

Date Tanggal

Time Jam

Reading Hasil

Gas Tester by / Pengetesan Gas dilakukan oleh : Name / Nama :

Sign / Tanda Tangan :

7. Work Permit Issued /  Pengeluara  Pengeluaran n Surat Ijin K Kerja erja The details of the permit have been discussed with the Permit Holder and those involved / Surat ijin ini telah dibahas secara rinci oleh Pemegang Ijin dan pihak -pihak yang terkait.

8. Authorization of Company (if required) / Penanggung Jawab Perusahaan (Jika diperlukan)

Authorized Person / Penanggung Jawab

Sign / Tanda tangan:

9. Issue and Acceptance / Pengeluaran dan Penerimaan Izin Kerja I have checked the worksite and the required precautions have been taken and discussed with all involved / Saya telah memeriksa area kerja dan pencegahan yang diperlukan dan telah dibahas oleh pihak-pihak terkait

10. Job Hand Over / Pengalihan Pekerjaan Permit Holder changed at / Perubahan Pemegang Izin pada

Name / Nama :

……………………. …hours / jam ..................... ....................................... .................. date /

Tgl

The in-coming Permit Holder and his workmen have been satisfactorily briefed on all the hazards and precaution / Pemegang ijin baru dan pekerjanya telah dijelaskan dengan rinci tentang potensi Bahaya dan Pencegahannya Outgoing Permit Holder / Pemegang Izin Lama :

---------------------------------------------------------------------------------------------------------------------Incoming Permit Holder / Pemegang Izin Baru : Permit Holder / Pemegang Izin Kerja 11. De-Isolations / Pelepasan Isolasi

Electrical / Mechanical / Elektrik Mekanik The electrical/mechanical isolations applicable to the Permit have now been removed / Isolasi Eektrik/Mekanik yang dipakai dalam izin ini telah dihentikan Electrician / Ahli Listrik

.........................................................

Mechanic / Ahli Mekanik

.........................................................

Isolator / Di isolasi oleh

.........................................................

--------------------------------------------------------------------------------------------------------------------------12. Suspension of Permit / Penundaan penggunaan Surat Izin Kerja I declare that the work for w hich this permit was issued has been temporarily suspended, all involved have withdrawn and the area/ equipment has been left in a clean cle an and safe state / Saya menyatakan bahwa Surat Izin Kerja yang telah diterbitkan ini ditunda  pemakaiannya  pemak aiannya se sementara mentara wa waktu, ktu, semua pihak ya yang ng terkait dita ditarik, rik, semua peralatan dan area kerja ditinggalkan dalam kondisi bersih dan aman Reason of suspension / Alasan Penundaan :

Authorization Person / Penanggung Jawab :

 

 

BANYU URIP PROJECT INFRASTRUCTURE FACILITIES EPC - 5

WORK PERMIT SYSTEM Doc No. IDBC-RH-SPZZZ-C00008

REV. 0

Health Safety Environment

12. Work Completion / Penyelesaian pekerjaan The above work has been completed. The worksite has been left safe, clean, and tidy / Pekerjaan diatas dinyatakan selesai. Lokasi pekerjaan ditinggalkan dengan bersih, aman dan rapi

Permit Holder / Pemegang Izin Kerja ......................................

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13. Permit Closure / Penutupan Izin Kerja The work has been inspected and is complete. co mplete. The Isolation have been removed and the area is safe / Pekerjaan diatas telah diperiksa dan selesai. Isolasi telah dihilangkan dan lokasi kerja dinyatakan aman ……………………………….....  

………………………… 

Authorized Person / Penanggung Jawab

Company (If Necessary) / Perusahaan jika perlu

Work Permit Extention Form / Form Perpanjangan Surat Izin Izin Kerja

No

Date / Tanggal

Time / Jam

Sign Tanda Tangan Contactor  Applicant

Consortium HSE

General Superintendent  Superintendent 

Client Representative  Representative 

1 2 3 4 5 6 7 Note :  Work Permit at any time may be revoked revoked or reviewed if the performed do does es not meet the requirements or provisions that safety required  Izin Kerja sewaktu-waktu dapat dapat dicabut atau di tinjau tinjau ulang jika pekerjaan pekerjaan yang dilakukan tidak memenuhi syarat atau ketentuan keselamatan yang disyaratkan