Project Name



|Project Name : | | |Project No. : | |

|Document No. : | | | | |

ISOLATION PERMIT

|ISOLATION PERMIT |No: |

|This Permit is for Isolation to : | | |

|Issued To : | | |Work location : | | |Type of Work: | | |

|Permit Holder : | | | | | | |

| |Print Name | |Signature | |Date | |

|AUTHORIZATION |

|Validity Period from : | |a.m| / / | |to: | |

| | |./p| | | | |

| | |.m.| | | | |

| |Print Name | |Signature | |Date | |

|Authorized by : | | | | | | |

| |Print Name | |Signature | |Date | |

|ASSESSMENT OF POTENTIAL HAZARDS |

|ENVIRONMENT & ISOLATION ASSESSMENT |

|What is involved? |Yes |No |N/A |What is involved? |Yes |No |N/A |

|Pipelines (water, steam, gas) |ο |ο |ο |Vessel pressurization |ο |ο |ο |

|Sludges/storm water (inrush) |ο |ο |ο |Electricity |ο |ο |ο |

|Fall of ground (excavation) |ο |ο |ο |Fire |ο |ο |ο |

|Chemicals |ο |ο |ο |Harmful materials |ο |ο |ο |

|CONTROLS REQUIRED |

|Main power source isolation |ο |ο |ο |Local area power isolation |ο |ο |ο |

|Circuit breaker isolation |ο |ο |ο |Emergency stop |ο |ο |ο |

|On-off switches |ο |ο |ο |Removable fuses |ο |ο |ο |

|Moveable parts blocked |ο |ο |ο |Suspended parts lowered |ο |ο |ο |

|Compressed fluids/gases drained |ο |ο |ο |Spring tension released/blocked |ο |ο |ο |

|All valves closed & locked |ο |ο |ο |All lines blinded & tagged |ο |ο |ο |

|Double block & bleed |ο |ο |ο |Extreme heat/cold dissipated |ο |ο |ο |

|Atmospheric testing |ο |ο |ο |Continuous monitoring |ο |ο |ο |

|Monitoring every ____ hrs |ο |ο |ο |Ventilation forced/natural |ο |ο |ο |

|Red Locks and tags |ο |ο |ο |Yellow Locks and tags |ο |ο |ο |

|Lockout Hasps |ο |ο |ο |Plug lock out device |ο |ο |ο |

|CONTROLS REQUIRED |Yes |No |N/A |CONTROLS REQUIRED |Yes |No |N/A |

|Circuit breaker lockout devices |ο |ο |ο |Cable lockout devices |ο |ο |ο |

|Valve lockout devices |ο |ο |ο |Pneumatic lockout devices |ο |ο |ο |

|Barricades |ο |ο |ο |Signage |ο |ο |ο |

|Ground support system stable |ο |ο |ο |Batters & benches stable |ο |ο |ο |

|Access for personnel |ο |ο |ο |Emergency rescue access |ο |ο |ο |

|PERSONAL REQUIREMENTS |

|Risk management completed |ο |ο |ο |JSEA training/communicated. |ο |ο |ο |

|Head protection |ο |ο |ο |Eye protection |ο |ο |ο |

|Face protection |ο |ο |ο |Fume/dust protection |ο |ο |ο |

|Hand protection |ο |ο |ο |Hearing protection |ο |ο |ο |

|Foot protection |ο |ο |ο |Clothing protection |ο |ο |ο |

|Fall protection |ο |ο |ο |Other body protection |ο |ο |ο |

|Additional PPE training |ο |ο |ο |Sentry |ο |ο |ο |

|Hot work permit | | | |Emergency equipment | | | |

|Notification - other departments |ο |ο |ο |Other requirements (continuing) |ο |ο |ο |

|EMERGENCY EQUIPMENT |

|List any emergency equipment required: |

| | | |

| | | |

| | | |

|OTHER REQUIREMENTS and ASSOCIATED DOCUMENTATION |

|List any relevant documentation/work-specific method statements/drawings or manufacturer’s instructions: |

| | | |

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|SHUT DOWN PROCESS |

|Operating Plant & Equipment shall be shut down using the following steps : |

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For Isolation and De-Isolation Processes, refer to the following page.

|START UP PROCESS |

|After Plant & Equipment has been de-isolated and energized, it shall be started up using the following steps : |

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|CLEARANCE FOR ISOLATION |Refer form I0216-SAF-FM-009C, Isolation Entry/Exit Log |

|All persons are clear of the area that was isolated by this Permit. Further work requires a new Isolation Permit. |

|Permit Holder : | | | | | | |

| |Print Name | |Signature | |Date | |

|COMPLETION OF WORK |

|Work covered by this Permit is Completed / Suspended. Further work requires a new Isolation Permit.(select one) |

|Permit Holder : | | | | | | |

| |Print Name | |Signature | |Date | |

|ISOLATION TYPE CODES |Isolation Permit No.: | |

|LVI |Low Voltage Isolation (< 1,000V) |HVI |High Voltage Isolation (( 1,000V) |DCR |De-Contactor Removed |GI |Gravitational Isolation |

|VLC |Valve Locked Closed |VLO |Valve Locked Open |SR |Spool Removed (blank fitted) |BI |Blank Inserted |

|RI |Radiation Isolation |HI |Hydraulic Isolation |MI |Mechanical Isolation |BE |Barrier |

|ISOLATION AND DE-ISOLATION PROCESSES |

|No. |Isolation Point |Iso|Isolation by |Cross Checked by |Special Precautions|De-Isolation | | | |

| | |lat| | |(Verification & | | | | |

| | |ion| | |Monitoring Req’ts.)| | | | |

| | |Typ| | | | | | | |

| | |e | | | | | | | |

| |Print Name | |Signature |Date: ……./……./…… | |Print Name | |Signature |Date: ….../……/… |

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