Polini Diversified Services Pty Ltd - Hot Work Pre-Notification

• Pre-notification Reference (DDMMYYYY - Site)

• Document No.

• Client

• Conducted on

  Date

• Prepared by

Section A - Description

• Site

  Select Narrakine Wandering North Williams Other Narrogin Williams

  • Narrakine
  • Wandering
  • North Williams
  • Other
  • Narrogin
  • Williams

• If Other:

• Description of work.

• Description of ground conditions where works are to be carried out.

  Select Bare Grassy Bitumen Concrete Gravel

  • Bare
  • Grassy
  • Bitumen
  • Concrete
  • Gravel

• Start time

  Date

• Estimated finish time

  Date

Section B - Weather Conditions (2 reds, do not complete works)

• Weather Risk Assessment

• Is there a machinery movement ban in the shire. If yes do not complete works.

  YES

  NO

• Temperature

  Select Hot 30+ deg Mild 20 to 30 deg Cool <20 deg

  • Hot 30+ deg
  • Mild 20 to 30 deg
  • Cool <20 deg

• Wind Levels

  Select Windy >15km Mild <15km Still

  • Windy >15km
  • Mild <15km
  • Still

• Are there flammable materials within 10m

  YES

  NO

Section C - Machinery Protection

• Machinery has been isolated and danger tags attached to main isolator.

  Yes

  No

  N/A

• Surrounding equipment has been isolated and airborne dust allowed to settle.

  Yes

  No

  N/A

• Any spouts or floor openings in the vicinity have been blocked to prevent hot materials falling through.

  Yes

  No

  N/A

• Has a suitable fire blanket been placed over any susceptible machinery.

  Yes

  No

  N/A

• If cutting in to an elevator or chute are the elevator buckets empty and the inside surfaces washed down.

  Yes

  No

  N/A

Section D - Preventing fire ignition and escape

• What suitable fire fighting equipment is present

  Select Fire fighting unit Fire extinguisher Water bucket Water hose

  • Fire fighting unit
  • Fire extinguisher
  • Water bucket
  • Water hose

• Has someone been designated to stand as fire watch. This, CBH inducted, person will be on watch for accidental combustion.

  Yes

  No

  N/A

• Who from CBH Operations has been notified of the issue of this permit?

• Company performing works?

• Spotter

  Sign

• Pre-notification issued by

  Sign