WORK PERMIT NO.:

Applicant name: Discipline: Phone:Work description:

Equipment/tools: :

Installation: Location/modul: Deck:Tag/line no.: Zone:Attachment::

WORK ORDER NO.:OPERATION NO.:ISOLATION NO.:

❏ Day ❏ Night ❏ Ongoing workDate: From hr: To hr:

Extended to hr:Area/Operations Supervisor Sign:CCR Technician Sign:Area Technician Sign:

OPERATIONS- AND SAFETY PREPARATIONS A B

APPROVAL/AUTHORIZATION

Area/Operations Other HSE Platform manager:Supervisor: position: Function:Remarks/requirements:

PRECAUTIONS PRIOR TO / DURING WORK EXECUTION A B

Safety system isolated/reactivated Signature:Isolated locally/CCRReinstated locally/CCRRemark:

Work site cleared according to requirementsArea Technician time: Signature:The work is cleared with CCRCCR Technician time: Signature:

Gastest - value

HCO2

H2S

Time/sign.

Precautions understood and are/will be fulfilled

Executing skilled worker Name: (Block letters)

COMPLETION A B

All locks/tags removed ❏ Yes ❏ NoEquipment ready for operation ❏ Yes ❏ NoArea Technician time: Signature:

Work cleared by CCR

CCR Technician time: Signature:

❏ Work completed ❏ Work not completed❏ Work place cleaned and securedExecuting skilled worker Signature:

Required Performed by area technician Signature❏ Depressurization❏ Draining/emptying❏ Cleaning/gasfreeing❏ Isolation by singel valve/double block&bleed❏ Isolation by blind/Isolation plan❏ Safety tag/lock❏ Venting/Extra ventilation❏ Prevent release of oil/gas in the area❏ Measures against radioactive radiation❏ Inspection of the area every hour❏ Other

GASMEASUREMENTS PRIOR TO/DURING THE WORK❏ Hydrocarbons every hour ❏ H2S every hour❏ Oxygen every hour ❏ every hour

ISOLATION SAFETY SYSTEM ❏ Locally ❏ CCRSystem:

Location/area:

Compensating measures:

❏ Work level 2

GR0216803_01_eng

Required Performed by executing skilled worker Signature❏ Portable gasdetector no. on the worksite❏ Verify mechanical isolation❏ Electrical isolation/lockingTag. No.:❏ Fire Extinguisher/fire prevention❏ Welding machine safely located and earthed❏ Continuous guard/radio communication❏ Drains blocked/covered❏ Barrier/warning sign/PA-announcement❏ Cooperate with CCR/Area technician❏ Follow requirements for work above sea/at height❏ Chemical data sheet known and available❏ Procedures/cheklist for the operation knownRef. No. :❏ Control of temporary lifting equipment❏ Follow requirements for Entry (confined space)❏ Special personal protective equipment

❏ Measures to avoid work related deseases

❏ Other requirements/preparations

1

2

3

4

5

❏ SAFE JOB ANALYSIS: NO:❏ REQUIRES APPROVAL FROM ELECTRICAL DEPARTMENT

LEV

EL 1

LEV

EL 2

Original: Work siteCopy:

Area (sketch/description)

N❏ Hot work A ❏ Pressure testing ❏ Well operation ❏ Work on hydro-❏ Hot work B ❏ Work above sea ❏ Explosives carbon system ❏ Entry (confined space) ❏ Dangerous substances ❏ Critical lifting operation❏ Isolation of safety system ❏ Radioactive materials ❏ Other/critical operation