SAFE WORK PERMIT CLASS- D RO SR

BLANKET SAFE WORK PERMIT CLASS- D SR. NO. ORIGINAL COPY

FINOLEX INDUSTRIES LIMITED

CAPTIVE POWER PLANT,

GOLAP-RANPAR, RATNAGIRI.MARK (V) WHEREVER APPLICABLE OR (X) WHEREVER NOT APPLICABLE. ORIGINAL COPY SHALL BE KEPT AT THE JOB SITE UNTIL WORK IS COMPLETE.

EXCAVATION, ROAD BLOCKAGE

SWP REQUESTED BY SHRI. _________ SIGN:_________ DEPT. :_______ SWP REQUIRED AT :______ HRS. ON:___________

ESTIMATED DATE OF WORK COMPLETION:_____________ ;

THE WORK TIMING WOULD BE FROM__________ HRS TO__________HRS / 24 HRS.

JOB AT PLANT / DEPT.:_______________ UNIT NO. ____________ LOCATION._______________________________________________________

JOB DESCRIPTION (MENTION THE PURPOSE ALSO) :

A) EXCAVATION :_____________________________________________________________________________________________________________

EQUIPMENT INVOLVED: POWER / HAND TOOL, _____________________________ APPROX. DEPTH _______MTRS.

BACK FILLING DETAILS: ____________________________________________________________________________________________________

B) ROAD BLOCKAGE : (SPECIFY ROAD NO.) _____________________________________________________________________________________

SWP ISSUED ON DATE:_________TIME:____________ HRS. VALID UP TO ___________HRS. ON DATE___________

THE WORK TIMING ALLOWED IS FROM:___________HRS TO:_____________HRS. OR 24 HOURS. ( )

PART 1 : FIRE & SAFETY DEPARTMENTS CLEARANCE:

- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED DRAWING OF THE FIRE HYDRANT SYSTEM. ( )

JOB CAN BE PERFORMED SINCE NO FIRE PIPELINE AND EQUIPMENT WOULD BE OBSTRUCTED.

- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED DRAWING OF THE FIRE HYDRANT SYSTEM, ( )

AND SINCE FIRE PIPE LINE AND EQUIPMENT NEARBY WOULD BE OBSTRUCTED JOB SHOULD BE PERFORMED WITH

EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS: ___________________________________________________________

____________________________________________________________________________________________________________________

SINCE ROAD NOS_______ WOULD BE BLOCKED ALTERNATIVE ROUTE NO.__________ FOR EMERGENCY MANAGEMENT WOULD BE UTILISED, IF REQUIRED. ALL THE DETAILS NOTED AND INFORMED TO F & S STAFF.

SHIFT IN CHARGE FIRE & SAFETY: SIGN:______________NAME:___________________________DATE:___________TIME:__________HRS

PART 2 : ELECTRICAL DEPARTMENTS CLEARANCE:

CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED ELECTRICAL AND TELEPHONE CABLES ( )

NETWORK DRAWING. JOB CAN BE PERFORMED SINCE NO ELECTRICAL AND TELEPHONE CABLES AND EQUIPMENT

WOULD BE OBSTRUCTED.

- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED ELECTRICAL AND TELEPHONE CABLES ( )

NETWORK DRAWING. SINCE THE NETWORK AND EQUIPMENT NEARBY WOULD BE OBSTRUCTED JOB SHOULD BE

PERFORMED WITH EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS: _______________________________________

___________________________________________________________________________________________________________________

SHIFT IN CHARGE ELECTRICAL DEPT: SIGN:___________NAME:___________________________DATE____________TIME:_________HRS

PART 3 : INSTRUMENTATION DEPARTMENTS CLEARANCE:

CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED INSTRUMENTATION CABLE NETWORK ( )

DRAWING. JOB CAN BE PERFORMED SINCE NO INSTRUMENTATION CABLES WOULD BE OBSTRUCTED.

- CHECKED PHYSICALLY THE TOTAL AREA TO BE EXCAVATED. REFERRED INSTRUMENTATION CABLES NETWORK ( )

DRAWING AND SINCE THE NETWORK AND EQUIPMENT NEARBY WOULD BE OBSTRUCTED JOB SHOULD BE

PERFORMED WITH EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS:_____________________________________________

___________ ____________________________________________________________________________________________________________

SHIFT IN CHARGE INSTRUMENTATION DEPT: SIGN:______________NAME:__________________DATE____________TIME:_________HRS

PART 4: CONSTRUCTION DEPARTMENTS. CLEARANCE:

- CHECKED THE PROPOSED AREA OF EXCAVATION, SURROUNDING BUILDING AND STRUCTURE AND UNDERGROUND ( )

PIPELINES. JOB SHOULD BE PERFORMED WITH EXTRA CARE AND BY TAKING FOLLOWING PRECAUTIONS: __________________

_________________________________________________________________________________________________________________________

ENGINEER CONSTRUCTION DEPT. : SIGN:__________________NAME:_________________________DATE____________TIME:_________HRS

PART 5 : AREA INCHARGES CLEARANCE :

PERMITTED EXCAVATION DEPTH:___________ MTRS INFORMED TO SECURITY ( )

BARICADING DETAILS: ______________________________________________________________________________________________________

BACK FILLING DETAILS:_____________________________________________________________________________________________________

SPECIFIC INSTRUCTIONS (if any) : ____________________________________________________________________________________________

SAFE WORK PERMIT IS ISSUED AFTER CONSIDERING ALL SAFETY ASPECTS & ADOPTING NECESSARY SAFETY PRECAUTIONS AND WILL BE EXECUTED BY ADOPTING SAFE WORK PROCEDURE. THE JOB, SAFE METHOD OF WORK, USE OF PPE, HOUSE KEEPING, EMERGENCY PREPAREDNESS & RESPONSE PROCEDURE, COMMUNICATION MEDIA ETC ARE CLEARLY EXPLAINED TO THE EXECUTING STAFF.

NAME OF SAFETY WATCH: SHRI______________________

Sign : ______________ NAME:__________________

DATE:________________ TIME :__________________HRS.

AUTHORISED Operations satisfaction

Sign : _____________ NAME:___________________

DATE : ______________ time:___________________HRS.

AUTHORISED MaintENANCE SATISFaction

SHIFTWISE CHECKING OF SPECIFIED CONDITIONS MENTIONED OVERLEAF SWP FOR CONTINUATION OF JOB.

SR. NO. DATESHIFTNAME OF

SAFETY WATCHOPERATIONS SATISFACTION

SIGNATURE NAME

MAITENANCE SATISFACTION

SIGNATURE NAME

AFTER ANY EMERGENCY OR STOPPAGE OF WORK FOR CERTAIN REASON ALL THE PARAMETERS OF THE SWP ARE RECHECKED AND SINCE FOUND SATISFACTORY RESTART OF THE JOB IS ALLOWED AND ENTRIES MADE.

JOB STOPPED FOR REASON : ----------------------------------------------------------ON AT : HRS.

SR. NO.DATESHIFTTIMEMAINTENANCE SATISFACTIONOPERATIONS SATISFACTION

SIGNATURE NAMESIGNATURE NAME

HANDING OVER

THE JOB IS COMPLETED [ ]

THE JOB IS INCOMPLETE. [ ]

BACK FILLING DONE AS INSTRUCTED. [ ]

BARICADING REMOVED. [ ]

HOUSE KEEPING DONE. [ ]

PERMIT RETURNED.

SIGN :____________NAME :______________

DATE : __________ TIME :_______________HRS.

AUTHORISED MaintENANCE SATISFactionTAKING OVER

WORK CHECKED. [ ]

HOUSEKEEPING DONE IS SATISFACTORY. [ ]

ROAD BLOCKAGE REMOVED, INFORMED [ ]

TO FIRE CONTROL ROOM AND SECURITY

WORK ACCEPTED

SIGN : ___________ NAME:________________

DATE____________ TIME :_________________HRS.

AUTHORISED OPERATIONS SATISFACTION

NOTE: THE PERMIT IS NOT VALID IN THE EVENT OF AN EMERGENCY. HOWEVER AFTER THE EMERGENCY IS OVER IT CAN BE REVIVED AFTER RECHECKING OF ALL THE CONDITIONS MENTIONED OVERLEAF AND THEN SUBSEQUENT CERTIFICATION OF THE SAME BY SIGNING FOR OPERATIONS SATISFACTION AND MAINTENANCE SATISFACTION. THE PERMIT IS VALID ONLY FOR THE PERIOD AND DURATION MENTIONED. ON EXPIRY OF VALIDITY NO EXTENSION IS PERMISSIBLE.

OVER NIN CASE, ELECTRICAL POWER TO BE ISOLATED/ RESTORED, THEN ELECTRICAL LOCK-

OUT/ LIFT-OUT (CLASS-E) PERMIT MUST BE ACCOMPANIED WITH THIS PERMIT. MASTER CARD IS A MUST FOR VESSEL

ENTRY ONLY.

(for extension pl. see over leaf )