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    F253 Permit System Component LOTO Isolation

    Uploaded by

    H Ali
    This document is a System/Component LOTO Isolation Permit Form that is used to request and approve the isolation of equipment through lockout/tagout procedures. It requires specification of the work, verification of isolation boundaries, approval signatures from managers, a safety tagging/sign-on sheet, and authorization from the HSE LOTO department before a permit can be issued. Upon completion, suspension, or cancellation of the work, the authorized person must sign off on the final section.

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    © All Rights Reserved
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    F253 Permit System Component LOTO Isolation

    Uploaded by

    H Ali
    18 views1 page
    This document is a System/Component LOTO Isolation Permit Form that is used to request and approve the isolation of equipment through lockout/tagout procedures. It requires specification of the work, verification of isolation boundaries, approval signatures from managers, a safety tagging/sign-on sheet, and authorization from the HSE LOTO department before a permit can be issued. Upon completion, suspension, or cancellation of the work, the authorized person must sign off on the final section.

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    F253 Permit System Component LOTO Isolation

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    This document is a System/Component LOTO Isolation Permit Form that is used to request and approve the isolation of equipment through lockout/tagout procedures. It requires specification of the work, verification of isolation boundaries, approval signatures from managers, a safety tagging/sign-on sheet, and authorization from the HSE LOTO department before a permit can be issued. Upon completion, suspension, or cancellation of the work, the authorized person must sign off on the final section.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views1 page

    F253 Permit System Component LOTO Isolation

    Uploaded by

    H Ali
    This document is a System/Component LOTO Isolation Permit Form that is used to request and approve the isolation of equipment through lockout/tagout procedures. It requires specification of the work, verification of isolation boundaries, approval signatures from managers, a safety tagging/sign-on sheet, and authorization from the HSE LOTO department before a permit can be issued. Upon completion, suspension, or cancellation of the work, the authorized person must sign off on the final section.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    System / Component LOTO Isolation Permit Form

    Permit No.:
    SYSTEM / COMPONENT LOTO (ISOLATION) PERMIT
    (Assigned by HSE LOTO)

    SECTION 1 - Specification of Work (PERMIT REQUESTOR)

    PERMIT REQUESTOR
    Contractor Phone / Contact No.
    Reason For Isolation- Full Description
    Primary Equipment to be affected
    Schematic Drawings & Diagrams (ref. No.): No MS/RA Ref. no., Schematic Drawings & Diagrams NO
    PERMIT
    Method statements Ref. No.:
    Area (PIER 1,2,3,4, CP1 or CP2) Level
    Gridline Reference Room No.
    Date Expired
    Date Received
    (BY HSE LOTO)
    Date Issued
    SECTION 2 - Isolation Boundary Verification

    I have verified the boundary and accepts responsibilities of the Isolations being requested.
    Permit Requestor (PR) Print Sign
    Name
    Date:
    Responsible Person (RP) Print Sign
    Name
    Date:
    SECTION 3 - Permit Approval must be signed before permit is submitted to HSE LOTO Office

    I, grant permission for the work to proceed Subject to all conditions from the checklist are met. I reviewed and check all associated test packs are approved. I declare that all information given in this permit is
    true and correct.
    Sign
    Manager / Area Supervisor Temporary
    Electrical Department (TEMPORARY POWER)
    Print Name
    Date:
    Subcon- T & C / Start up / MEP Manager Sign
    Print Name
    Date:
    MAIN CONTRACTOR / Start up / MEP Manager Sign
    Print Name
    Date:
    SECTION 4 - SAFETY TAGGING / SIGN ON SHEET (SEE SECOND PAGE)

    SECTION 5 - TAGGING AUTHORITY (TA) - HSE LOTO DEPARTMENT must be signed before permit is ISSUED to AUTHORIZED PERSON / REQUESTOR

    I have checked that the Isolation Points identified in the Safety Tagging Permit Requestor (PR) is sufficient and authorize the work to proceed.
    HSE LOTO TAGGING AUTHORITY Sign
    Print Name
    Date:
    SECTION 6 - COMPLETION, SUSPENSION OR CANCELLATION of WORK
    All work associated with this Electrical Permit has been:

    COMPLETED * CANCELLED * SUSPENDED *


    All work associated with this Electrical Permit has been:
    Additional Comments:

    Sign
    Authorized Person / Permit Requestor (PR)
    Print Name

    Date:

    AFET-IMS-F253| HSE | Permit – System / Component LOTO Isolation Permit Form| Issue 1 | Rev 0 | Jun '17

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