COMPANY: ______________________ WORK PERMIT Code

CAUSALITIES FOR SUSPENSION OF THE PERMIT: THE OCCURRENCE OF A SITUATION OF ALERT, EXPLOSION, FIRE, EVACUATION SIGNAL
CHANGE OF CLIMATE CONDITIONS OR EXPRESS ORDER OF THE PERSON WHO AUTHORIZES DETERMINES THE SUSPENSION OF SAME. Indicate other causes if
there are
_____________________________________________________________________________________________________________________________________
2. IN CASE OF EMERGENCIES OR ACCIDENT CONTACT:________________________ TEL_____________________ EXT______
3. Date and time of authorization of the permit DD/MM/YY:______________________ Valid from HH/MM ______________________am/pm Until HH/MM ________________________am/pm

4. Name of the authorizing person:_______________________________ Dept.______________________________________

5. Nombre de quién Solicita:_______________________________ Dpto.______________________________________

6. LIST OF AUTHORIZED WORKERS
NAMES AND SURNAMES DOCUMENT OF SIGNATURE EPS ARP
IDENTITY

7. SECTION I - COLD WORK PERMIT - Complete in all Permits

8. The work is LIMITED to the following (Scope of Work - Description and Area/Team) That, how, and for what ____________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________

9. The good condition of the tools and equipment was verified before starting the work: N/A

Hand tools Tool holder Others. Which ones? _________________________

Electric, pneumatic, hydraulic tools, etc. Straps for securing tools

Electric extensions Ladder

Others, which ones?

10. Identify and remember the main dangers of the activity and their controls

Noise Chemical inhalation (solution, liquid or gas) Contact with hydraulic energy Fire Asphyxiation

Vibration Contact with chemical product (solid, liquid or gas) Contact with pneumatic energy Explosion Environmental damage

Temperature Contact with animals Risk of entrapment Other risks. Which ones? _________________________

Radiation Load manipulation Falls from height _____________________________

Insufficient lighting. Contact with electrical energy A/M/B Particle projection ______________________________________________

11. The following personal protective equipment required according to the identified hazards and signage was verified. N/A

Clothes Foot and leg protection Barriers/Warning signs

Overall Safety boots with toe cap Danger

Pet Dielectric boots Caution

Manguillas Others: __________________________ Perimeter Demarcation

Gaiters Hearing protection Others:__________________________

Others Insert Type Retention and fall equipment

Others:___________________ Type cup Harness Lanyard

Facial and ocular protection Respiratory protection Lifeline Safety net

Neutral lens holder Respiratory for cartridges type ____________ 1/2 face complete way Anchor Points

Monogafas Disposable mask for ______________ Gloves

Oxy-fuel glasses Head protection Leather (Vaqueta or chamois) Lona

Welder's helmet Helmet Rubber Resist. to the drop

Others_______________________ Boy in fabric or leather Nitrile Dielectrics

12.- The personnel in the potentially affected area and the workers were notified of the work to be done. YES N/A

13.- They were communicated to the permit recipient: His responsibilities Conditions for interrupting the permit Applicable safe work procedures

Indicate the name of the applicable procedure: _______________________________________________________________________________________________________

14.- Check with the authorized workers to develop the activity that they know. N/A
Yes N/A Yes N/A

A.- Emergency exits and evacuation routes B.- The meeting points in case of emergency

C.- The dangers of your activity D.- The safe work procedures applicable to your activity

E.- The area brigadistas and how to locate them F.- The location of emergency equipment (first aid kits, fire extinguishers, stretchers, etc.)

15. SECTION II - HOT WORK - Complete this section and section I to carry out hot work. N/A
Si Yes

A.- Clean the work area by removing flammable or combustible products F.- Turn off the suction system

B.- Monitor the explosive atmosphere (use of explosimeter) G.- Turn off ventilation system

C.- Isolate the work area using screens, tarps. H.- Electrically block the machine or equipment
D.- Cover all existing openings in order to prevent the dispersion of sparks I.- Mechanically lock the machine or equipment
E.- Bring portable fire extinguishers to the work area J.- Use inert gas

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SECTION III - WORK AT HEIGHT - Complete this section and section I to carry out work at height. N/A
Yes S

A.- Mark the work area with danger tape The relevant signage for the work to be done was placed.

WORK WITH LADDERS N/A

A.- The ladder is suitable for the work to be done (CERTIFIED) B.- The ladder was fixed at the top

C.-The slope of the stair is adequate D.- The ladder was inspected
The support surfaces of the ladder are firm and regular. F.- Do workers know the safe work procedures with ladders?

WORKING WITH SCAFFOLDS N/A

A.-The ground where the scaffolding rests is firm The foot guards were installed on the work platform.

C.-The scaffold is well leveled The perimeter railings were installed on the work platform.

E.- The scaffold is certified F.- In case the Scaffolding is not certified, it is in good condition.

The boards and work platforms are in good condition. There are anchor points outside the scaffold.

I.-The planks are free of cracks and knots All the cross braces were secured with the pins.

The planks protrude from the supports enough on each side. The scaffolding was secured.

The planks overlap at least 20 cm at the joints. N. Winds were used in guaya or another mechanism to secure the scaffold.
The scaffold is certified. Do the workers know the procedure for working with scaffolding?

WORK WITH ELEVATING BASKET, FORKLIFTS OR MANLIFTS N/A

A.-The ground where the equipment rests is firm and flat B.- The perimeter tape was installed.

C.-The elevator/lift is functioning properly It was verified that there are no obstacles in the trajectory

It was verified that the weight does not exceed the capacity of the equipment. A lifeline needs to be installed.

Communication radio is required H.- Workers have appropriate harnesses and insurance to secure themselves.

I.- The basket was secured to the loading lift.

[Link]ÓN IV- TRABAJOS EN ESPACIOS CONFINADOS - Completar está sección y la sección I para realizar [Link] espacios confinados N/A
If N/A Yes N/A

A.- There are secure means of access to the workplace B.- The entrance guards are present.
C.- Appropriate personal protective equipment (PPE) is available for the activity There is a means of communication between the workers and the guard.

The necessary isolation was carried out to prevent the entry and exit of fluid. The atmospheric testing equipment is calibrated and functioning correctly.

G.- El area se ha delimitado para prevenir el acceso de personal no autorizado H.- The measurement of the atmosphere (oxygen, explosive, flammable, and toxic) was carried out.

I.- The conditions for cancelling the permit are clear. J.- The atmospheric measurements of toxic substances are below the TLV.

K.- The lighting and communication equipment is explosion-proof. Oxygen between 20.5 and 22.5%

M.- Forced ventilation is available N.- LEL = 0

Are the self-contained breathing apparatuses available for the guard? There is no visible presence of oil mist.
A harness, ropes, extinguishers, and other elements are available to handle emergencies. There is danger signage appropriate for the work to be carried out.
Workers in the area are familiar with the use of autonomous equipment. The portable lighting is explosion-proof.
It is necessary to cut off the supply of gas/electricity/mechanical energy. V.- The worker was trained for the use of autonomous equipment
It is necessary to cut the electrical power.

19. SECTION IV - ELECTRICAL WORK N/A

Yes N/A Yes N/A

A.- The visible cut of the possible sources of tension has been made. D.- The grounding or short circuit was carried out (if necessary)

B.- The blocking or pinning was carried out at the cutting points E.- Se instalaron las señales de advertencia necesarias
C.- The absence of voltage was verified with the multimeter. Are the PPE and necessary equipment available?

20. ATMOSPHERIC TEST TEST DATE ____________ ESTABLISHED FREQUENCY _____________________

TEST TIME

LEL %

O2%

CO, ppm
PROCESS FOR THE AUTHORIZATION OF THE PERMIT FOLLOW UP FOR THE CLOSURE OF THE PERMIT

WHO AUTHORIZES THE

WHO REQUESTS WHO REQUESTED WHO AUTHORIZED
START OF WORK:

Company..................................................................... Company.................................................................Company....................................................... Company.....................................................................

Aclaración:........................................................... Aclaración:.........................................................Aclaración:............................................... Aclaración:...........................................................

THE OPERATION OR ENERGIZATION IS AUTHORIZED UPON EXPIRATION OF THE PERMIT

WAS THE WORK AUTHORIZED? YES NO
YES NO

21. ADDITIONAL COMMENTS WHEN OPENING THE PERMIT [Link] OF PERMIT

DATE OF EXTENSION HOUR

EXTENSION DATE HOUR

23. ADDITIONAL OBSERVATIONS WHEN CLOSING THE PERMIT AND CONSIDERATIONS FOR THE NEXT DAY

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