Doc.

No : HSSE/PSP-01/STONOR
Effective Date : 11/08/2017
CONTROLLED AREA Revision : 00
PERMIT Section Reference
IKHMAS JAYA SDN. BHD.
10.5 : Permit to Work System
(Company No : 254017-H)

Project : Permit No. :

Application must be submitted prior to work commencement.

Permit requested by : Permit is required :
Name From To

Signature Date

Date Time

Name of Company : (if work carried out by third party)

Description and Nature of Work : Location / Work Area :

Supervisor in Charge :

Safety Requirements to be Complied Weekly EHS Re-endorsement

Work in accordance with method Barricade the working area and provide Week
statement and risk assessment. warning signs. (Name/Date/Time)

Conduct toolbox meeting on the safe No incompatible work is allowed e.g.

work procedures. flushing of chemicals. Week
(Name/Date/Time)
Task lighting and access lighting must be Clear away all combustible materials near
provided for night work. the working area.
Provide ventilation. Fire extinguisher/fire hose standby. Week
(Name/Date/Time)
Install flashback arrestor. Maintain good housekeeping.
Mount gas cylinders on trolley. Use of adequate PPE.
Week
PIC supervision must be provided at all Helmet with chin strap must be used and (Name/Date/Time)
time. chin strap must be secured at all time.
Communication methods established. Flagman/standby-person if required.
Week
Emergency action plan established. (Name/Date/Time)
No smoking zone

APPROVALS: Name Card No. Contact No. Date Signature

Permit Receiver

Permit Issuer

IJSB HSE

WORK COMPLETED: Date _______________________ Time ____________________________

Permit Receiver (Name/Signature) Permit Issuer (Name/Signature)

Note:
This permit must be displayed at the work area. If there is no place available for display, keep permit at a place where it is retrievable.
All appropriate signatures must be obtained before work start.
The original permit must be returned to EHS Department upon work completion.