IZIN KERJA PANAS
PT. SIWICS METAKOMPRESI PRATAMA
HOT WORK PERMIT
No. Izin Kerja : Izin berlaku mulai : Hingga :
Permit No. Valid from Until
Tanggal : Lokasi (Unit/Area/Bangunan) : Peralatan yang digunakan :
Date Location ( Unit/Area/Building) Equipment / Tools used
Kontraktor :
Contractor
Uraian Pekerjaan :
Description of work
PEMERIKSAAN KESELAMATAN DITEMPAT KERJA / SAFETY INSPECTION AT WORKING AREA
Dilakukan oleh Pengawas Lapangan dan Pengawas Pelaksana / Conducted by Site Authority and Performing Authority
Pemadam Api tersedia Toolbox Meeting/Safety Talk Peralatan Las / Potong
Fire Equipment available Conducted Toolbox/Safety Talk Welding/Cutting Tool
Alat telah diisolasi Alat Pelindung Diri (APD) Wajib Bahan bakar diamankan
Equipment has been isolated PPE Mandatory Combustibles protected
Rambu Peringatan terpasang SOP/SWP disiapkan Alat Angkat telah diinspeksi
Warning Sign is in place SOP/SWP has been prepared Isolasi Lifting equipment pass the inspection
Alat bantu pernafasan tersedia Listrik/Mekanis Electrical/Mechanical Jalan keluar/masuk tersedia
Breathing Apparatus has been prepared has been isolated Pencegahan Access has been prepared
Prosedur Darurat diketahui Pencemaran Bagian dalam bejana telah dibersihkan
Emergency Procedure acknowledge Conducted spill prevention Inside vessel has been clean up
Pengawas keselamatan disiapkan Hewan berbahaya bawah air diantisipasi Pengukuran LEL,O2,H2S,CO dilakukan
Safety Personnel in place Hazard underwater animal has been Test LEL,O2,H2S,CO has been conducted
anticipated
Blower udara disiapkan Kerusakan lingkungan telah dicegah Test kesehatan dilakukan
Air blower has been prepared Environmental damage has been prevented Medical test has been conducted
PEMERIKSAAN SERTIFIKAT KETERANGAN / CONFIRMATION CLEARANCE CERTIFICATE
Oleh Pengawas Daerah / By Area Authority
Analisa Keselamatan Kerja Pengelasan Penyelaman
JSA and Risk Assessment Welding Lifting Operation
Pemeriksaan Kesehatan Perancah Isolasi Listrik/Mekanis
Medical Test Scaffolding Electrical/Mechanical Isolation
Serah Terima Area Bekerja di ketinggian Radiography
Hand Over Area Working at height
Alat Pelindung Diri (APD) tambahan
Additional PPE Requirement
PEMERIKSAAN OLEH PETUGAS YANG TERLATIH Jika pemeriksaan gas melebihi ambang batas,
Test by Competent Person hentikan pekerjaan
Stop the work if gas test result exceed threshold
Hasil pemeriksaan / Test result Gas Test
Waktu / Time
Hydrocarbon LEL % H2S ppm O2 % Atmosphere
Jarak test
Interval time
Diperiksa oleh
By
Paraf
Sign
CATATAN KHUSUS DARI PENGAWAS DAERAH
Special Notifications from Area Authority
Pengawas Lapangan koordinasi dengan departemen terkait untuk mendapatkan bantuan atau
jaminan bahwa pekerjaan bisa dilakukan dengan aman / Site Authority shall coordination with related
department to get assistance or warranty that the work can be safety done
Saya telah mengerti kondisi yang tertera di surat izin ini dan akan menjelaskan kepada regu kerja sebagaimana mestinya dan akan meninggalkan
tempat kerja dalam keadaan bersih dan aman / I understand the conditions laid down by this permit and will brief the work crew accordingly and will leave the
site clean and safe condition
Pengawas Pelaksana/Performing Authority : Nama/Name : Tandatangan/Sign :_ Wakt u/Time :_
Petugas Keselamatan/Safety Personnel : Nama/Name :_ Tandatangan/Sign : Waktu/Time:_
Saya telah meninjau kembali seluruh persiapan dan cara kerja dan memberi izin kerja untuk dikeluarkan / I have reviewed and all precautions and
methods of work and authorized the permit to be issued
Pengawas Lapangan / Site Authority : Nama / Name:_ Tandatangan/Sign:_ Waktu/Time :_
Pekerjaan dapat dimulai bila persyaratan tersebut diatas telah dipenuhi / Work may commence providing all the above conditions have been meet
Pengawas Daerah / Area Authority : Nama/Name :_ Tandatangan/Sign :_ Waktu/Time :_
PERPANJANGAN IZIN KERJA / Permit Extension Permit ini akan diperpanjang / This permit may
Perpanjangan izin kerja harus melampirkan Analisa Keselamatan Kerja dan Identifikasi Bahaya / be extend
Job Safety Analysis and Hazard Identification have been attachment for permit extension
Izin diperpanjang mulai :_ Hingga : Pengawas Daerah / Area Authority
This permit is extended from Until Nama dan Tandatangan / Name & Sign
PENYELESAIAN PEKERJAAN / Work Completion
Saya pastikan bahwa pekerjaan ini telah selesai dan dapat diterima, seluruh pagar pengaman dan tanda-tanda keselamatan telah dikembalikan
pada kondisi semula / I have confirmed tha the work has been completed and accepted, all safety barriers and signs have been restored
Pengawas Pelaksana/Performing Authority Nama/Name: Tandatangan/Sign: Waktu/Time:_
Pengawas Lapangan/Site Authority: Nama/Name:_ Tandatangan/Sign:_ Waktu/Time :_
Distribusi : Putih (Pengawas Lapangan), Kuning (Pengawas Pelaksana), Biru (Arsip)
Distibution : White (Site Authority), Yellow (Performing Authority), Blue (File)
SIWICS-FRM-3025, 1 Mei 2014, Rev. 0
