WORK PERMIT /ﺗﺻﺭﻳﺢ ﻋﻣﻝ Reset Form Print Form
WP is valid for 24hr can be extended daily for another 6 days / ﺗﺻﺭﻳﺢ ﻋﻣﻝ ﺳﺎﺭﻱ ﺍﻟﻣﻔﻌﻭﻝ ﻟﻣﺩﺓ ﺃﺭﺑﻌﺔ ﻭﻋﺷﺭﻳﻥ ﺳﺎﻋﺔ ﻳﻣﻛﻥ ﺗﻣﺩﻳﺩﻫﺎ ﻳﻭﻣﻳﺎ ﻟﻣﺩﺓ ﺳﺗﺔ ﺃﻳﺎﻡ ﺃﺧﺭﻯ
Date / ﺍﻟﺗﺎﺭﻳﺦ: 18/4/2018 Time / ﺍﻟﻭﻗﺕ: 3:00 PM Work Duration / ﻣﺩﺓ ﺍﻟﻌﻣﻝ: 24 HOURS PTW No / ﺭﻗﻡ ﺗﺻﺭﻳﺢ ﺍﻟﻌﻣﻝ:
Related WP / ﺗﺻﺎﺭﻳﺢ ﺫﺍﺕ ﺍﻟﺻﻠﺔ: WP#
Contractor # / ﺭﻗﻡ ﺍﻟﻣﻘﺎﻭﻝ: CP-117 Permit Requestor / ﻁﺎﻟﺏ ﺍﻟﺗﺻﺭﻳﺢ Mohamed Rady Mobile No / ﺭﻗﻡ ﺍﻟﻣﻭﺑﻳﻝ: 01006664161
Equip. Desc./ ﻭﺻﻑ ﺍﻟﻣﻌﺩﺍﺕ: System /ﻧﻅﺎﻡ: EY 1
Unit / ﻭﺣﺩﺓ:
sst transformer Equipment Tag #:
Work Description / ﻭﺻﻑ ﺍﻟﻌﻣﻝ ﺍﻟﻣﻁﻠﻭﺏ
cable testing (continuity)
Does the work involve special activities? / ﻫﻝ ﻁﺑﻳﻌﺔ ﺍﻟﻌﻣﻝ ﺗﺗﻁﻠﺏ ﺍﻱ ﻣﻥ ﺍﻻﻋﻣﺎﻝ ﺍﻟﺧﺎﺻﺔ ؟
Confined Space Entry / ﺩﺧﻭﻝ ﺍﻻﻣﺎﻛﻥ ﺍﻟﻣﻐﻠﻘﺔ High Voltage / ﺍﻟﺟﻬﺩ ﺍﻟﻌﺎﻟﻲ Operating System / ﺍﻟﻣﻧﻅﻭﻣﺔ ﺗﺣﺕ ﺍﻟﺗﺷﻐﻳﻝ
Hot Work / ﺍﻋﻣﺎﻝ ﺳﺎﺧﻧﺔ Energized Panel / ﺍﻟﻛﺎﺑﻳﻧﺔ ﺗﺣﺕ ﺍﻟﺟﻬﺩ ﺍﻟﻛﻬﺭﺑﻲ Excavation / ﺍﻟﺣﻔﺭ
Removal of Flooring / ﺇﺯﺍﻟﺔ ﺍﻷﺭﺿﻳﺎﺕ Pressurized line /ﻣﻭﺍﺳﻳﺭ ﻣﺿﻐﻭﻁﺔ Others / ﺍﻋﻣﺎﻝ ﺍﺧﺭﻱ
If YES to any of the above then complete the relevant certificate and attach to the WP. Also attach risk assessment form.
. ﻛﺫﻟﻙ ﻳﺟﺏ ﺍﻥ ﻧﺭﻓﻖ ﻣﺎ ﻳﻔﻳﺩ ﺑﺗﺣﻠﻳﻝ ﺍﻻﺧﻁﺎﺭ ﺍﻟﻣﺻﺎﺣﺑﺔ ﻟﻠﻌﻣﻝ ﻭﻛﻳﻔﻳﺔ ﺗﻔﺎﺩﻳﻬﺎ. ﻓﻳﺟﺏ ﺍﻥ ﻧﺭﻓﻖ ﺍﻻﻭﺭﺍﻕ ﺍﻻﺯﻣﺔ ﻣﻊ ﺗﺻﺭﻳﺢ ﺍﻟﻌﻣﻝ, ﺇﺫﺍ ﻛﺎﻧﺕ ﺍﻹﺟﺎﺑﺔ ﻧﻌﻡ ﻋﻠﻰ ﺃﻱ ﻣﻥ ﺍﻟﻧﺷﺎﻁﺎﺕ ﺍﻟﺳﺎﺑﻖ ﺯﻛﺭﻫﺎ
LOTO (attached) / (ﺧﻁﻭﺍﺕ ﺍﻟﻌﺯﻝ )ﻣﻁﻠﻭﺑﺔ YES /ﻧﻌﻡ NO / ﻻ Risk Assessment (attached) (ﺗﻘﻳﻳﻡ ﺍﻟﻣﺧﺎﻁﺭ )ﺍﻟﻣﺭﻓﻘﺔ YES /ﻧﻌﻡ NO / ﻻ
Other Contractors related to this Work Permit / ﺍﻟﻣﻘﺎﻭﻟﻳﻥ ﺃﺧﺭﻯ ﺫﺍﺕ ﺻﻠﺔ ﺑﻬﺫﻩ ﺗﺻﺭﻳﺢ ﺍﻟﻌﻣﻝ
Contractor # ﺭﻗﻡ ﺍﻟﻣﻘﺎﻭﻝ Name / ﺍﻻﺳﻡ Signature / ﺗﻭﻗﻳﻊ
Contractor # / ﺭﻗﻡ ﺍﻟﻣﻘﺎﻭﻝ Name / ﺍﻷﺳﻡ Signature / ﺗﻭﻗﻳﻊ
Contractor # / ﺭﻗﻡ ﺍﻟﻣﻘﺎﻭﻝ Name / ﺍﻷﺳﻡ Signature / ﺗﻭﻗﻳﻊ
List Operating Areas Affected Special Conditions Required / ﺍﺣﺗﻳﺎﻁﺎﺕ ﺧﺎﺻﺔ ﺍﻟﻣﻧﺎﻁﻖ ﺍﻟﻣﺗﺄﺛﺭﺓ ﻧﺗﻳﺟﺔ ﺍﻟﻌﻣﻝ ﺍﻟﻣﻁﻠﻭﺏ ﻗﺎﺋﻣﺔ
Permit Condition Acceptance / Signatures/ ﺍﻟﺗﺻﺩﻳﻖ ﻭﺍﻟﻣﻭﺍﻓﻘﺔ ﻋﻠﻲ ﺍﻟﺗﺻﺭﻳﺢ Contractor WP Responsibility / ﺍﻟﻣﻘﺎﻭﻝ ﺍﻟﻣﺳﺋﻭﻝ ﻋﻥ ﺍﻟﺗﺻﺭﻳﺢ
I certify that proper safety precautions have been taken in accordance with the golden rules of safety and all workers involved in this job task have received a safety brief and fully
understood all permit conditions required. No work tasks will be performed except those listed on PTW.
WP Authorizes Name / ﺍﺳﻡ ﻣﺳﺋﻭﻝ ﺍﻟﻌﻣﻝ Mahmoud el badawy Authority /HSE Name:
Sign/ ﺍﻟﺗﻭﻗﻳﻊ Mobile No / ﺭﻗﻡ ﺍﻟﻣﻭﺑﻳﻝ01005276660 Sign ﺍﻟﺗﻭﻗﻳﻊ/
Contractor Construction/ Commissioning Manager/…………………………....................... Site Manager /…………………………………… As required
PGESCo WP Approval PGESCo WP Issued
Comm & SU Mech. Elect. I&C Const. Civil. PGESCo Operations:
Name / ﺍﻻﺳﻡ Name / ﺍﻻﺳﻡ
Signature / ﺗﻭﻗﻳﻊ Signature / ﺗﻭﻗﻳﻊ
Date / ﺗﺎﺭﻳﺦ: Time / ﺍﻟﻭﻗﺕ Date / ﺗﺎﺭﻳﺦ: Time / ﺍﻟﻭﻗﺕ
As Req. PGESCo SU/Oper. Manager: As Req. PGESCo HSE:
Permit Revalidation / ﺗﺟﺩﻳﺩ ﺗﺻﺭﻳﺢ ﺍﻟﻌﻣﻝ
Day 2 Date Sign Day 5 Date Sign
Day 3 Date Sign Day 6 Date Sign
Day 4 Date Sign Day 7 Date Sign
WP Hold / ﺍﻳﻘﺎﻑ ﺗﺻﺭﻳﺢ ﺍﻟﻌﻣﻝ
Permit Requestor shall remove all locks and tags and return Work Permit to PGESCo and no further work may be conducted until Work Permit is released
Permit Requestor name: PGESCo Operations:
Signature / ﺗﻭﻗﻳﻊ Signature / ﺗﻭﻗﻳﻊ
Date / ﺗﺎﺭﻳﺦ: Time / ﺍﻟﻭﻗﺕ Date / ﺗﺎﺭﻳﺦ: Time / ﺍﻟﻭﻗﺕ
WP Release / ﺍﻟﺳﻣﺎﺡ ﺑﺎﻟﻌﻭﺩﺓ ﻻﺳﺗﻛﻣﺎﻝ ﺍﻟﻌﻣﻝ
Permit Requestor name: PGESCo Operations:
Signature / ﺗﻭﻗﻳﻊ: Signature / ﺗﻭﻗﻳﻊ
Date / ﺗﺎﺭﻳﺦ: Time / ﺍﻟﻭﻗﺕ Date / ﺗﺎﺭﻳﺦ: Time / ﺍﻟﻭﻗﺕ
Work Completion / ﺍﻻﻧﺗﻬﺎء ﻣﻥ ﺗﻧﻔﻳﺫ ﺍﻟﻌﻣﻝ
The plant has been restored to normal & safe condition and all Tags have been removed / ﺗﻢ اﻻﻧﺘﮭﺎء ﻣﻦ اﻟﻌﻤﻞ واﻋﺎدة اﻟﻤﻮﻗﻊ اﻟﻲ ﺣﺎﻟﺘﮫ اﻟﻄﺒﯿﻌﯿﺔ وﻓﻲ ﺣﺎﻟﺔ اﻣﻨﺔ
Permit Requestor / ﻁﺎﻟﺏ ﺍﻟﺗﺻﺭﻳﺢ: …………………………………………Sign. / اﻟﺘﻮﻗﯿﻊ:…………………………….....Date/ اﻟﺘﺎرﯾﺦ: ………………….Time / ﺍﻟﻭﻗﺕ: …………
Contractor Repair Report Attached YES /ﻧﻌﻡ NO / ﻻ
PGESCo WP Completed / ﺍﻻﻧﺗﻬﺎء ﻣﻥ ﺍﺩﺍء ﺍﻟﻌﻣﻝ PGESCo WP Closed / ﺍﻧﻬﺎء ﺗﺻﺭﻳﺢ ﺍﻟﻌﻣﻝ
Comm &SU Mech. Elect. I&C Const. Civil. PGESCo Operations:
Name / ﺍﻻﺳﻡ Name / ﺍﻻﺳﻡ
Signature / ﺗﻭﻗﻳﻊ Signature / ﺗﻭﻗﻳﻊ
Date / ﺗﺎﺭﻳﺦ: Time / ﺍﻟﻭﻗﺕ Date / ﺗﺎﺭﻳﺦ: Time / ﺍﻟﻭﻗﺕ
