SAFE WORK PERMIT

WORK PERMIT No:

Hot work Working at heights Another AREA (Graphic description of location)
LEVEL 1
Entry to confined spaces Critical Uprisings N
FALL PROTECTION ELEMENTS AND ACCESS SYSTEMS NECESSARY FOR THIS JOB.
Anchoring mechanisms Carabiners Descender eight Scissor stairs
Anchor points Strap for restriction Jumar Descender Extendable ladders
Horizontal cable lifelines Hoist for positioning Troll (brakes) Fixed stairs
Horizontal life lines rope Sling for detention Pulleys Elevators
Vertical cable life lines Full safety harness Tripod Scaffolding
Vertical lifelines rope String Others Cranes with basket
Others
Date of Issue Issued To (Department/Contractor) VALIDITY
DAY MES YEAR FROM UNTIL
Installation Area Day Night Work in progress
Applicant Cargo Extended until:
Descripción del trabajo: General Area Chief Company
Supervisor Company
Does it require approval from the electrical department? YES NO
Names of the workers involved: This work permit is valid only until the end of the work shift and for the specified conditions.
existing at the time of its initiation. It expires as a result of the occurrence of hazards such as leaks
gas, spill of flammable liquids, drastic changes in operation, rainy weather, disobedience of
safety standards, and even the occurrence of a work accident.

SECURITY MEASURES
HOT WORK CONFINED SPACES ELECTRICAL RISK CRITICAL UPRISINGS WORK AT HEIGHTS
The team or area is free The team has been identified and The team has been identified and The tools were checked and An inspection was carried out of the
of gases, pressure, hot substances? electrically disconnected electrically disconnected? materials to be used? fall protection systems?
Are the equipment in service? The fluids are disconnected. Marked and signaled area? Marked and signposted area? Marked and signposted area

Is the ATS located? The equipment is free of gases. The connections were inspected. Was the overhead crane inspected? An inspection was conducted of
pressure and hot substances? boards and substations? tools?
Has the work area been delimited? The valves are closed and Equipment is available The conditions of the Inspection of scaffolding (anchoring,
Are the blind flanges installed? fire fighting? load? scissors, clips, held dogs, etc.
Staff induction was carried out in They have been purged and blocked the Is the area clear? There is visual signage or Inspection of stairs (steps,
risk prevention? instrument lines and sampling auditory that prevents the use of extension elements, hooks, pulleys
The teams are found and This is the clean area for products. Staff induction was conducted in Is the crane equipped with a fire extinguisher? Se realizó inducción al personal en
tools in good condition? other combustible materials risk prevention the prevention of risks?
Equipment is available The starters have a lifeline or Is the ATS located? The crane has the capacity table. Disclosure of emergency plan
fire protection? rescue team? of load? (rescue and self-rescue)
Induction was conducted for the staff in The pulleys were inspected and A lookout is found with the
the prevention of risks? guavas? operator as a preventive action?
Is the ATS located? The equipment controls are in The tools are located
good condition? secured to prevent falls?
Equipment and others are found Is the ATS located? Is the ATS located?
tools in good condition?
PERSONAL PROTECTIVE EQUIPMENT, NECESSARY EQUIPMENT AND SAFETY ELEMENTS FOR THIS JOB
helmet PVC gloves Gaiters Fire extinguishers
Safety boots Hearing protection Assisted air equipment Demarcation love
Safety glasses Welder's helmet Signaling elements Oxygen detector
Cotton gloves Respiratory protection Radio transmitter/receiver Others:
Leather gloves Reflective vest First aid kit
Dielectric gloves Work clothing (overalls) Spill kit
Facial protection Meat bone Explosimeter

NOTIFICATIONS WORK TEAM MEASURES UNDERSTOOD AND WILL BE CARRIED OUT BY

NAME NAME NAME
SIGNATURE COMPANY
CARGO CARGO PERSONA (LEADER) EXECUTIVE OF THE WORK

APPROVALS TO EXECUTE THE WORK

AREA MANAGER SUPERVISOR HSEQ Manager DATE AND TIME

NAME NAME NAME

COMPLETION
Have cards and/or blocks been removed? N/A YES NO Work completed Work NOT completed Clean and secured site
Are the teams ready to operate? YES NO Person executing the work Company
Site Supervisor HOUR SIGNATURE CLOSURE AND CANCELLATION
Area verified by Supervisor HOUR SIGNATURE HSEQ Manager HOUR SIGNATURE

IMPORTANT!

This Work Permit format serves as a guide for identifying hazards and risks associated with the critical work to be carried out within the concessioned area. This guide does not replace the
obligations of Colombian law and technical standards established for issues related to Industrial Safety, Occupational Health, and Environmental Protection.