Professional Documents
Culture Documents
Name of Project :
Date:
Permit No. :
Work location :
Type of Work to be done : Storm water Manhole cleaning
H2S Monitor
Hard Hat
Safety Shoes
Hearing Protection
Coverall
Safety Harness
Air Respirator
SAFETY PRECAUTION
Sl.No.
Safety Measures
Work area been inspected and reasonable precautions taken to ensure that no
potential Hazard exists
YES
NO
I understand and agree that no work is permitted other than that specified on this permit. I have check both permit and the job, and understand the
and precaution to be followed in completing the work
Engineer/ Supervisor
Signature :
Date :
Signature :
Date :
Signature :
Date :
Checked by:
Safety Officer
Issued by:
Project Engineer
Signature :
Date :
Signature :
Date :
Revision 0
AGP/HSE/SF/029
Revision 0
Signature :
Date :
AGP/HSE/SF/029
Remarks
Time :
Time :
Time :
Time :
Revision 0
AGP/HSE/SF/029
Time :
Revision 0
AGP/HSE/SF/029