KING ABDULLAH PORT POWER PLANT

Document#: KAP-EHS-Form/003

JOB ORDER NUMBER: ______________________ WORK PERMIT NUMBER:

PREVIOUS WORK ORDER # : OBSERVATION JUSTIFIED : YES:

NO:
System: Unit/Area: Date:

Equipment to be worked on:

Requestors Name: Priority : 1 2

3

Job Description

Type of personal protection equipment Required:

Safety Shoes Safety Helmet Dust Mask Ear Muff Coverall

Safety Vest Cotton Gloves Safety Goggle Electrical Gloves Safety Harness
Observation during the job:

Will any SAFETY EQUIPMENT be out of service during the period of this work permit? YES NO

Are mechanical Lock Out / Tag Out necessary during the period of this work permit? YES NO

Are LV Electrical Lock Out / Tag Out necessary during the period of this work permit? YES NO

Are MV Electrical Lock Out / Tag Out necessary during the period of this work permit? YES NO

If “YES” in any of above questions, please fill and attach form EHS/004 to the Work Permit.

Special Fire guard required during the period of this work permit. YES NO

Is barring of the working area necessary. YES NO

If job is pending due to any reason : Plant Manager
(Acknowledgement)

PERMIT VALID

From To
Maintenance Engineer Safety
Shift Engineer Requestor
Engineer
Date Time Date Time

Result of job:
Date:_________
___ Time:__________

Maintenance
Engineer____________________
Check list Yes No Sign Safety equipment is back Yes No Sign

Mechanical isolation removed

in operation

Electrical isolation removed Date :

Work Permit Closed/Cancelled

__________________ ______________ ___________________________
Date Time Shift Engineer