PT.
PACIFIC MITRA BERSAMA
Marunda KBN
IZIN BERKERJA / PERMIT TO WORK (PTW)
Nomor / Number : ………………………………….............
Berlaku Tanggal & Jam / Effected Date & Time : …………………………………………………
Sampai Tanggal & Jam / Until Date & Time : …………………………………………………
1 PEKERJAAN / WORK ACTIVITIES 2
TINDAKAN PENCEGAHAN OPERASIONAL /
Diisi oleh Pemohon, Kontraktor atau Pemegang Permit OPERATIONAL PRECAUTION
/ To be completed by Applicant, Contractor or Permit Diisi oleh SHE & Operational Dept. / To be completed
Holder. by SHE & Operation Dept.
Uraian Kerja, Lokasi & Pelaksana ? / Description Apa isi Produk yang ada dalam peralatan (pipa,
Nature of work, pompa, tangki) ? / What Product is contained in the
equipment ?
Site & Executor ? ___________________________________________
Any Flammable product contained in the equipment ?
- Uraian kerja / Description : Tingkat bahan mudah terbakar / Flammability Class
Ya (Yes) / Tdk (No)
If yes please fill up 2(a)
I II III 2a
2a Perhatian yg dibutuhkan / Precautions
- Lokasi / Location : Required
Ya (Yes) / Tdk (No)
Tekanan pada alat dihilangkan /
Depressurise Equipment
Draining kargo pada peralatan /
Drain Equipment
- Pelaksana / Executor : Isolasi peralatan / Isolate Equipment by :
Spades / Blinds
Removing Spool Piece(s)
Double Block Valves
Flush Equipment by air / water
Purge Equipment by air or N2
Lainnya / Other :
____________________________________
____________________________________
Jenis Pekerjaan / Type of work Dibutuhkan Tambahan Sertifikat /
Dismantling, Assembling. Sand Blasting. Additional certificate required
Fabrication (No Hot Work) Electrical. Ya (Yes) / Tdk (No)
Draining and/or Cleaning. Calibration. Pekerjaan di Ruang Terbatas / Confined Spaces
High Pressure Working. Working at height Sertifikat perancah, tangga,
Excavating (except dry bulk operation) Scaffold, ladder and gondola Certificate
Lainnya / others : Pekerjaan Penggalian / Excavation
______________________________________ Sertifikat Listrik / Electrical Certificate
______________________________________
______________________________________ Rev. High Pressure /
Rev. High Pressure Working
Note : Hot work (grinding/soldoring/brezing industrian Adakah Resiko Lainnya / Additional Risk :
drilling/welding) any type of work consist of fire harzard __________________________________________
Pekerjaan panas (Penggilingan/Menyatukan/Mematri __________________________________________
pengeboran industri / las) setiap jenis pekerjaan terdiri dari
__________________________________________
bahaya api
PT. PACIFIC MITRA BERSAMA
Marunda KBN
Peralatan yang digunakan / Tools APD (Alat pelindung Diri) /
PPE (Personal Protective Equipment)
* Peralatan Tangan Listrik / Electric Hand Tools :
____________________________________________ Rubber Boots
____________________________________________ Hand Gloves
____________________________________________ Ear Plug,Ear Muff
* Peralatan untuk Bekerja di Ketinggian / Breathing Apparatus
Working at Height : Full Face Respirator
Perancah / Scaffold Safety Goggles, Face Shield
Tangga / Ladder Life Jacket
Gondola Safety Harness (Fall Protection)
* Peralatan Listrik / Electrical non-Protected : Safety Helmet
Lainnya / Others :
Generator Compressors
___________________________________________
Pumps
___________________________________________
* Alat Berat / Heavy Equipment :
Excavator Crane
Forklift Stamper / Jackhammer
* Lainnya / Others :
___________________________________________
___________________________________________
3 INSTRUKSI KEPADA PEMEGANG IZIN KERJA / INSTRUCTIONS TO PERMIT HOLDER
Diisi oleh SHE Dept. / To be completed by SHE Dept.
Instruksi Umum / General Instructions :
1. Areal kerja selalu harus dalam keadaan BERSIH / Work place to be kept tidy at all times
2. Ketika mendengar bunyi ALARM, stop semua pekerjaan, matikan semua mesin, pindahkan semua sumber
nyala dan laporan untuk berkumpul di assembly point / Upon hearing ALARM stop all activities, shut down all
engines, remove all ignition sources and report to gathered at assembly point.
3. Mesin harus dimatikan pada kondisi / Equipment must be switched off when :
- Ada tumpahan di areal kerja / spillage occurs in the working area.
- Diperintahkan oleh Personil PT.PMB yang bertugas / Instructed by PMB personnel in charge
4. Setiap hari setelah bekerja / At the end of each working day :
- Bersihkan areal kerja / clear up the work area (housekeeping)
- Pisahkan sampah B3 & Non B3 / Separate toxic waste & non toxic waste
5. To submit all certificate and supporting ducument during application.
4
5. LEMBAR PENGESAHAN / APPROVALS
MENYETUJUI / APPROVED MENYETUJUI / APPROVED
PEMOHON / APPLICANT KETERANGAN / REMARKS
Permit Officer MCT – HSE
Contractor/Maintenance/Operation (By HSE)
By applicant Company (Manager)
Approve Yes / Approve No
Nama : Nama : Nama :
Tanggal / Jam : Tanggal / Jam : Tanggal / Jam :
