LOCATION
Sl. No.______________ ________________ /___________
VALID FROM___________ DATE________________ AM/PM
UPTO___________ DATE________________ AM/PM
Note: THIS PERMIT SHALL BE VALID FOR THE ABOVE SPECIFIED PERIOD NOT EXCEEDING 45
DAYS
PERMISSION IS GRANTED TO SECTION or CONTRACTOR
____________________________________________________________
NAME_______________________________________________________________________
NATURE OF WORK IN DETAIL FOR WHICH THIS WORK PERMIT IS VALID
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
________________
LOCATION OF WORK (Specific area inside the RO) -
____________________________________________________________________________
THE FOLLOWING ITEMS SHALL BE CHECKED BEFORE ISSUING THE PERMIT
(Please put tick [ ] mark in the appropriate box)
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Sr. No Item Done Not required
1. Equipment or Work Area inspected [ ] [ ]
2. Surrounding area checked, cleaned [ ] [ ]
and covered (ensuring product is not
exposed to atmosphere in the
working area)
3. Identify the Equipment to be repaired
and switch off its electric supply
(equipment electrically isolated [ ] [ ]
and tagged)
4. Portable extinguisher and sand [ ] [ ]
buckets provided
5. Blocking of sources of product or [ ] [ ]
product vapour of pipeline or tank
equipment (Equipment blinded or
disconnected or closed or isolated or
wedge opened)
6. Removal of left over product in [ ] [ ]
tank or pipeline or equipment taken
up for works
7. Equipment water flushed [ ] [ ]
8. Pyrophoric Iron removed or kept wet [ ] [ ]
9. Proper ventilation and lighting [ ] [ ]
provided
10. Gas test done, found gas free [ ] [ ]
11. Standby personnel provided [ ] [ ]
(confined space entry viz tank entry and like other entries)
SPECIAL INSTRUCTIONS
1. Following personal protective equipment are required (check all items required): safety helmet
or safety
gloves or protective goggles or safety shoes or safety belt
2. In case of fire alert, all work must be stopped. All personnel must leave work site and proceed
to
designated or on site directed areas.
3. Remarks on toxic or hazardous chemicals, if any.
4. Alternate means of escape available or provided or not required.
5. This permit must be available at work site at all times.
6. Additional items, if any:
_________________________________________________________
I have duly explained the nature of the work, risk involved and all the safety precautions to be
followed to the
vendor and his supervisor for implementation, as well as to the dealer and his authorized
representative for
monitoring the same. This permit shall be valid till the work as mentioned in “Nature of work” is
completed.
Name and _______________
Signature of Officer ____________
I have understood the risk involved and the safety precautions explained to me by the oil
company officer and I
shall monitor the work in accordance with the same till the work as specified under the “Nature of
Work” is
completed.
Name and _____________________
Signature of dealer or authorised manager _____________
I have understood the risk involved and the safety precautions explained to me by the oil
company officer and I
shall carry out the work in accordance with the same, till the work as specified under the “Nature
of Work” is
completed.
Name and _____________________