Reliance

Reliance Projeet Mansgement

Group
Industries Limited

Reliance Project Management System

Permit to Work
RPMS-HSEF-CHK-HC-061

01 09.01.18 Issued for Approval SA SM JT

Rev Date Revision Details Revised Checked Approved

By By By
 Relianc
P er o

Reliance Project Management System P e r mt

iot

Permit to Work RPMS-HSEF-CHK-HC-061

Date: 09/01/2018, Rev. 1

RECORD OF REVISIONS
Date Revision Details Revision Number
Checked by Approved by
Issued for
19.08.2013 Sudhir Mishra
Implementation Brian Spraker

09.01.2018
Issued for
01 Sudhir Mishra
Implementation James Thorn
 RPMS-HSEF-CHK-HC-061
Reliance Project Management System
Permit to Work Date: 09/01/2018, Rev. 1

Assessment of Task Checklist

(This checklist must be completed before Permit to Work is issued)
Before issuing a Permit to Work, the Issuer must review the job
and consider the following:

STOP 1

2
Do you know exactly what the intended job
Do you need to personally visit the work
entails?
area?
know exactly?
3 Does the employee about to do the job also
4 Does the Permit to Work fall within
your level of
authorization?

Have you considered?

Hazards
Portable Electrical Equipment
Accessibility
Pressure
Area Classification

Cramped Work Area Process and Other Liquids

Radioactive Emissions
Dust, Powders, Solids
Residual Process Materials
Electric Power
Restricted Field of Vision
Fumes, Odors
Services - Steam, Water, Air
Gases, Flashing Liquids
Temperatures
lgnition of Surrounding Material
Motive Power Traffic Ways

Noise Vapor
Obstructions, Falling Objects Weather Conditions

Other People Welding Flash

Other Sections Working at Height
Adjacent Steady State Activities
Precautions

Atmosphere Testing Frequency Hearing Protection

Auxiliary Lighting Ladder, Scaffolding

Breathing Protection Safety Spectacles
Emergency Exit Route Standby Person(s) - How many?
Permit to Work (RPMS-HSEF-CHK-HC-061) Page 3 of 8
© 2018 Reliance Industries Ltd.
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work Date: 09/01/2018, Rev. 1

Environmental Safeguards Standby Person's Briefing

Footwear Standby Person's Protection
Gloves Ventilation
Goggles Written Procedure
Head Protection IFR Suit

Contractors
Supervisor Appointed Site Statutory Induction Completed
Dress Standards/Protective Clothing Names on Plant Access Board
PPE Checked
ID Badging, where appropriate
Test Date of Eguipment Checked Contractor Licenses Checked
Contractor Insurance Checked HSE Training Completed
Plant Standards Communicated
Skill Training and Accreditation
Contractor Briefing Completed Checklist Completed
Permit to Work

Company Name:
Qiemexg LtDate: lo2l25
Project Name:
33 ky GTR, MRSO4 ProjectNo/Contract No: 412l23o17381Z
Area:
alyalicon Aaea, MRS&4 Permitetto WorkkNo.: 9E)8L|2TA- 40
P&ID No.(s): Equipment No.:
Equipment
bas bendinDescription:Qpjll maçhine, HilH bmeñcIeR, Conaele mixca, vibaccos, plgcetlinq machike
"AHvities Authorized by t
(provide details, specifics, and limitations below)
Excavations (slope <1.5:1) Blasting Vegetation/Ground
Clearing
Wall Penetrations Simple Lockout/Tagout Radiography
Ceiling/roof Penetrations Performed From Below
Other (describe):
Job Description
(describe details, specifics, limitations)

Satalatingftehon. andaiemaadlin, shutuing and deshuleing otblck

glates ing concach chiping,malail Shittna, kloading aud loadng of
muaony uck
Peh
mit <(RPMS-HSEF-CHK-Nc-061) Page 4of 8
© 2018 Reliance Industries Ltd.
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work
Date: 09/01/2018, Rev. 1

Precautions and other Information

(Describe in detail)
Is this Job a Modification? Yes No Modification No.:
Work Order No.:
Is "Assessment of Task Checklist" Current?
Client Coordinator:

Hazards
None Expected
Electricity voltage: Others Working Nearby
Gas
Working at Heights Solids
Liquid Hot Surfaces Overhead/Adjacent
Power Lines
Molten Metal Stored Energy Varmints

Engulfment/Hazardous Engulfment/|DLH Active/Energized Utilities

Atmosphere Atmosphere
Premature Explosion Earth Cave-in Other
Other Other Other

Additional Permit(S) Required

None Required Use of Suspended Access to High Voltage
Personnel Workbasket Areas

Hot Work Energized ElectricalWork Critical Lift

Confined Space Roof Access Line Break

Entry
Hot Tap Excavation Break-In

Tagout Authorization Form (TAF) Process/Lockout Grating/FIloor

Tagout Plate/Guardrail Removal
Working Near Overhead/Adjacent Power Lines
Protective Equipment
StaFdard Clothing Gloves (type): Canister/Cartridge
Reflec've Tackes Cut Resisdant Respirator
Hot Work Clothing Chemical Goggles Rubber Boots

Permit to Work (RPMS-HSEF-CHK-HC-061) Page 5 of 8

© 2018 Reliance Industries Ltd.
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work
Date: 09/01/2018, Rev. 1

Faceshield Hearing Protection Safety Harness

Helmet and Glasses SCBA or Airline PVC Jacket
Respirator
Fall Protection Other PVC Pants
Isolations
Note: Only those isolations meeting the criteria in Table 1 of
can be allowed by a Permit to Work without a TAF. RPMS-HSEF-PRA-HC-071

None Required As Below

Item Description Method Check for Isolation De-isolation
Dead
INTL Date Time INTL DateTime

All Authorized Workers must hang personal locks and

Danger Tags on each isolation.
The building or plant item described above is, in my opinion, in a safe
job to be done provided the conditions above are fully condition for the
observed. These conditions
have been discussed with, and understood by, the persons involved.

Permit to Work Issuer

Issuer Name
SigFature Date Time Valid Until Time
PonkojKy I72-2s lo, osHh 23 o2-2s
Acceptance and Return
This permit is only valid when above parts have been completed.

Recipient Taking Permit to Work:

Thave read this Permit to Work and have had the hazards and
precautions explained to
me; I willcomply with these provisions. Should there be a change in conditions that
introduces new hazards to the task, Ior the work party will stop work and notify the
Permit to Work Issuer. Work will only proceed with apprOval from the Issuer. I, or the
work party, willvacate area on request or alarm. Iwill not interfere with online
equipment.
Recipient Signature Organization Date Time Completed
Permit to Work (RPMS-HSEF-CHK-HC-061) Page 6 of 8
O 2018 Reliance Industries Ltd.
Reliance Project Management System RPMS-HSEF-CHK-HC-061
Permit to Work Date: 09/01/2018, Rev. 1

Name

|Askae Sicmenclu t7|o2(2S Yes No

No
Yes
Yes No

Yes No

Responsible person has signed on for others.

All Authorized Workers must hang personal locks and Danger Tags on each isolation.

Recipient Handing Back Permit:

lor my work party have withdrawn from the job. Unless the job is incomplete, tools,
materials, and equipment from the immediate vicinity of the work area have been
removed, flange guards replaced, personal locks and Danger Tags removed, and the area
cleaned.

Recipient Signature Organization Date Time Completed

Name

Yes No

Yes No

Yes No

Yes No

Job Complete
The plant/system/area is, in my opinion, available for safe return to service. This Permit
to Work is now withdrawn.

Permit to Work Issuer

Issuer Name Signature Organization Date Time (24 hr)

T 93) 242S
Permit to Work Extension

The plant/system/area described above is, in my opinion, in a safe condition for the job
to be done provided the conditions above are fully observed. These conditions have
been discussed with, and understood by, the persons involved.

Permit to Work Issuer

Issuer Name Signature Date Time Valid Until Time

Permit to Work (RPMS-HSEF-CHK-HC-061) Page 7 of 8

O 2018 Reliance lndustries Ltd.
Reliance Project Management System
Permit to Work RPMS-HSEF-CHK-HC-061
Date: 09/01/2018, Rev. 1

Acceptance and Return

This permit is only valid when above
parts have been completed.
Recipient Taking Permit to Work:
Ihave read this Permit to
Work and have had the hazards and
me; I will comply with these precautions explained to
provisions. Should there be a change
introduces new hazards to the task, I or the work party will stop in conditions that
Permit to Work Issuer. Work willonly proceed with work and notify the
work party, will vacate area on approval from the Issuer. I, or the
request or alarm. Iwill not interfere with online
equipment.
Recipient Signature Organization Date
Name Time Completed

Yes No

Yes No

Yes No

Yes No
Responsible person has signed on for others.
AllAuthorized Workers must hang personal locks and Danger Tags on each
isolation.

Recipient Handing Back Permit:

Iand /or my work party has
withdrawn from the job.
materials, and equipment from the immediate vicinityUnless the job is incomplete, tools,
of the work area have been
removed, flange guards replaced, personal locks and Danger Tags
cleaned. removed, and the area
Recipient Signature Organization Date Time
Name Completed

Yes No

Yes No

Yes No
Yes No
Note: This form is referenced in Practices
016, RPMS-HSEF-PRA-HC-065, RPMS-CONS-PRA-CM-001, RPMS-HSEF-PRA-HC
RPMS-HSEF-PRA-HC-068,
HSEF-PRA-HC-078, and RPMS-HSEF-PRA-HC-079. RPMS-HSEF-PRA-HC-071, RPMS

Permit to Work (RPMS-HSEF-CHK-HC-061)

Page 8 of 8
© 2018 Reliance Industries Ltd.
 Recipient Taking Permit to work:

Date Time Issuer Name

Sign Accepter Sign Extended up Sign
Name to

Acchel
TCE
Sah
|902-2s
fonkejkR Acehel
Sah
mka Nime
Kumar
Nome
Kamar
2al)251o'gotu |VH:Sh r4n |Nimal

Recipient Handing Back Permit:

Date Time Issuer Name Sign Accepter Name Sign

Acchelal
|?o2 2s 20:otty Ponkoj TOE
Sah
Acckela
|922S

|4lo2s amkasv Wme

Kumar
Aolps 30}00 Hotss \Melgmax
VkShrqa