WORK PERMIT (PTW)

Izin Keselamatan Kerja - CS77 Standard

ACTIVE

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1. General Information

Permit Number (Auto)

Permit Type *

Valid From *

Valid To *

Exact Location / Area *

Job Description / Scope of Work *

2. Personnel & Responsibilities

Issuing Authority (IA) *

Performing Authority (PA) *

Area Authority (AA) *

Gas Tester (if applicable)

3. Hazard Identification & Control Measures

Identified Hazards

Flammable Atmosphere Toxic Gas (H2S/CO) Falling from Height Electrical Shock Pinch / Crush Points Falling Objects

Control Measures / Perlengkapan K3 Required

Safety Helmet Safety Shoes Safety Glasses Gloves Full Body Harness Personal Gas Detector Fire Extinguisher LOTO Equipment

JSA / JSA Reference Number

4. Isolation / LOTO

Type of Isolation Applied

Electrical Isolation Mechanical Isolation Process Isolation Pneumatic Isolation Hydraulic Isolation Line Breaking / Flushing

Lock Number

Tag Number

Isolation Point Description

Saya menyatakan isolasi telah diverifikasi dan dipasang LOTO dengan benar.

5. Gas Test Record

Time of Test

Oxygen (O2) %

Lower Explosive Limit (LEL) %

H2S (ppm)

CO (ppm)

6. Approval & Signatures

Draw signature using mouse or finger. Signatures will appear in the PDF.

Issuing Authority (IA) - Name IA Signature

Sign here (IA)

Performing Authority (PA) - Name PA Signature

Sign here (PA)

Area Authority (AA) - Name AA Signature

Sign here (AA)

Date & Time of Approval

7. Permit Closure Checklist

Fill only after work is completed. All items must be checked before closure.

Pekerjaan telah selesai sesuai lingkup kerja Area telah dibersihkan (housekeeping) Semua alat telah dipindahkan LOTO telah dilepas dan energi dikembalikan Barrier dan rambu telah dilepas Area diserahkan ke Area Authority Tidak ada bahaya sisa

Closed By (Name)

Closure Date & Time

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Handcrafted with ❤️ by Andrew Dwiranto (Cah_Sragen_77, Indonesia)