Title Page
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Company Name
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Company rep
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Person supervising
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Area to which permit applies
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Job information
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Risk Assessments shown
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competency certificates shown
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Isolations
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Circuit breaker locked out/ fuses removed
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Double check circuit is dead
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Valves closed/locked off
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Pipelines drained/ purged/ disconnected/ vented
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Precautions
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Protective clothing
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Respiratory Equipment
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Non sparking tools
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PAT tested equipment used
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Scafftag
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Ladder certificates
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Additional precautions
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Additional permits and signatuers
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Are any additional permits required
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Issue
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Issue Permission is given for the work to start
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Acceptance I have read understood and accept the conditions of this permit
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Change of shift
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Clearance
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All men under my charge have been withdrawn
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This permit is cancelled all work completed
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