Permit to Work Major Hazard Standard - MIRMgate

WMC EHS Management System Major Hazard Standard
Permit to Work
APPENDIX B
B
WORK PERMIT
WORK PERMIT
No:
Plant / Area :
Equipment Description:
Scope of Work:
Equipment No.:
Work Permit Register No.:
THA / SWP No.:
NO WORK OUTSIDE OF THIS SCOPE MAY BE PERFORMED UNDER THIS PERMIT
SPECIAL PRECAUTIONS AND CONDITIONS
Work Permit certificates Y/N Number Y/N Number
Isolation
Excavation
Confined Space Entry
Radiation
Hot Work
Testing Program
Plant Change Applicable -------------
Any other conditions
Work Permit Authorisation
I acknowledge that all preparatory work has been completed and that work is safe to proceed.
Permit Issuer:
Signature:
Date:
Time:
I fully understand the hazard controls in place for this work to proceed.
Permit Acceptor:
Signature:
Date:
Time:
Work Permit Closure
I confirm that the work is complete and the work environment is in a clean and safe state.
Permit Acceptor:
Signature:
Date:
Time:
I have confirmed that work is complete and the job site is safe to return to normal duty.
Permit Issuer:
Signature:
Date:
Time:
AUTHORITY TRANSFER, WORKER SIGN ON REQUIREMENTS ON REAR OF THIS FORM
WMC-EHS-MHS-007 DocsOpen Ref : 155520 Issued: 23/12/03 Page 18 of 59