Permit to work for LOTO
Ref. No. - BHQ/HSE/PRO/PO 007 - LOTO Work Permit
LOCKOUT TAG OUT PERMIT
Location Date Time
Department Permit for Hours
Description of work:
Engineer Name Agency
Section-1 Energy isolation
Equipment Name Lock Contact
box no
Equipment has been depressurized, drained, and
cooled:
Equipment has been de-energized
Equipment has been locked or tagged per equipment
procedure
Do blanks need to be installed prior to work activities?
Necessary tags, warning devices and signs have been
placed?
Have maintenance / service workers been briefed on
process hazards?
Did line/equipment contain ANY of the following
chemicals: oxygen, Hydrogen, methanol, ethanol,
propane, ammonia or natural gas?
Fire extinguisher and fire control system available at site
Did all valve closed and tag properly
Keep area free from combustible materials.
Keep area barricade and isolate all services
Section-2 Personal protective Equipment
Safety Shoes/ Safety helmet Safety jacket Safety goggle
boot
Respiratory mask Ear plug Safety Apron Acid hood thermal
Rubber hood Safety belt Life line other
Other Precaution..-
Permit Conditions And Requirements Approvals
Permit to work for LOTO
Ref. No. - BHQ/HSE/PRO/PO 007 - LOTO Work Permit
acseptance
Permit issuer Engineer Review by HSE
Engineer and responsible person
Approved By PM
This Permit Is To Be Kept On The Job Until Work Is Completed, Permit Expires.
