PERMIT TO WORK SN:

RISK LEVEL:
Section 1 - Work Information Section 5 - Approvals & Acceptance
Area Owner : TGPP Start Date Expiry Date
Contract Owner (Name/Dept): EV CADUNGOG PTW Validity
CMMS Work Order No./Contract No.: 51794 ( Maximum PTW Validity : 20 Days )
PTW Holder: AD GORDO JR. Date Time Name /Signature
PTW Applicant/Company: RE POVADORA / EVC PTW Issuer ER DAGLE
Work Scope: PTW Approver RP ABLEN
PTW Holder AD GORDO JR.
REPLACEMENT OF SEALPOT AND ITS TUBING PTW Applicant RE POVADORA
Section 6 - Re-Issue (NOTE: DO NOT REISSUE if there are changes
Facility/Equipment Description: in the associated clearance/s.)

SEALPOT & TUBING

PTW Holder
Equipment Number: SH-U1 PTW Issuer
Job Location & Work Boundaries (indicate specific work site and physical limits; attach
sketch if needed):
PTW Holder
GCGI STEAM HEADER UNIT 1
PTW Issuer
Section 2 - Associated Clearances (Mark "1" all that apply)
Section 7- Renewal
Hazardous Energy Isolation ( HEI)* Date Time Name /Signature
Fire Protection Impairment (FPI)* PTW Issuer
1 Work at Heights (WaH)* PTW Approver
Excavation and Trenching ( ET)* PTW Holder
Work on Slope (WOS)* PTW Applicant
Critical Lift ( CL): Mobile Crane Overhead Crane
Entry into Confined Spaces and Toxic Atmosphere areas
1 Work on Energized Electrical Equipment (WEE) PTW Holder
Hot Work (HoW) PTW Issuer
Well Bleeding/Discharge (WBD)
legend: * = co terminus with PTW
Section 3 -Hazards Identification (check all that apply) PTW Holder
Hazard Identification PTW Issuer
Biological (Insects, animals) Overexertion
Caught Between Objects Oxygen Deficiency Section 8- Transfer of PTW Holder
Chemical Burns Poor Lighting/Visibility Outgoing PTW Incoming PTW Holder
PTW Issuer Date / Time
Contact with Objects Poor Ventilation Holder PTW Holder Supervisor
Dust, Airborne Particles Poor Weather Conditions
Electric Shock/Arch Flash Spill or Release
Engulfment(landslide/cave-in) Struck Against/Struct By
Ergonomics/Body Position Slippery/Uneven Surface Section 9- Transfer of PTW Applicant
Exposure to Toxic Gas Slips, Trips, Falls Outgoing Incoming Applicant's
PTW Issuer Date / Time
Exposure to Radiation Thermal Burns Applicant Applicant Supervisor
Fire or Explosion Wounds, Laceration
Heat Stress Others (specify):
Noise
Other items that may affect activity: Use separate Transfer page if needed.
OH/UG Utilities
Is there a Hold Point for Witnessing/verification of measurement Section 10 - Permit Cancellation
Hold Point Activity/location? Date Time Name & Signature
Is there an existing work/s that will potentially create PTW Cancelled by:
hazard from simultaneous activity? PTW Returned by:
Section 4 - Hazard Controls/ Personal Protective/Safety Equipment State Reasons for Cancellation:
Item Y N n/a
Work Area isolated with signs/barriers
Fall Protection Section 11 - Work Completion and Close Out
Gas badge Y N n/a
Safety goggles/gloves/apron Is the job complete?
Ear Protection Have energy isolations been removed and eqpt
Face Protection returned to service?
Foot Protection Has the work area been restored and cleaned up?
Head Protection Have all tools and equipment been removed?
Respirator Have all PTW documents been returned?
SCBA All members of the work party are accounted for?
Nearest safety shower & eyewash located? PTW Closed by:
Oil/Chemical spill kits available? Date Time Name / Signature
Radio Area Owner
Mandatory Attachment PTW Applicant
JHA PTW Holder
Pre Task Mtg PTW Issuer
PTW Approver
 PTW ENGR's COPY
SN:
Job Hazard Analysis & Risk Assessment Form
Section 1 - Work Information
WORK ACTIVTY DESCRIPTION JOB LOCATION

REPLACEMENT OF SEALPOT AND ITS TUBING GCGI STEAM HEADER UNIT 1

Section 2 - JHA & RA Table

Hazards FINAL RISK
INITIAL RISK ASSESSMENT
Identified ASSESSMENT (Residual Risk)
Potential
Sequence of Job Steps, Tools Injury or
& Equipment Used For Job Environment Hazard Controls
Step strike against
Damage Risk Risk
sharp or L C Level L C Level
jagged edges

Preparation of materials and tools
Caught on Wound 2 1 2 Conduct housekeeping and remove any 3 1 3
protruding object that has a sharp or jagged
edges; remove jewelries (such as ring,
necklace, and the like), watch; put a yellow
caution tape and safety signage; designate a
person to oversee the barricaded area and
warn anyone to keep away from the barricade

Arrange materials according to its
type or kind
Caught on wound 2 1 2 Conduct housekeeping and remove any 2 1 2
protruding object that has a sharp or jagged
edges; remove jewelries (such as ring,
necklace, and the like), watch; put a yellow
caution tape and safety signage; designate a
person to oversee the barricaded area and
warn anyone to keep away from the barricade

Overexertion_Lift Back pain, 3 2 6 Lift w/ your legs, load must be closed to the 3 1 3
ing Damage to spinal body, Use trolley if available, Do not lift heavy
chord load or avoid manual handling

Hauling of materials and tools to the Overexertion_Lift Back pain, 3 2 6 Lift w/ your legs, load must be closed to the 3 1 3
area ing Damage to spinal body, Use trolley if available, Do not lift heavy
chord load or avoid manual handling

Remove old tubings Strike against Wound, pain 3 2 6 Place end cap of protruding rebars, pipes and 3 2 6
stationary objects the like; Conduct housekeeping; remove
protruding object; clear the area; check
surrounding hazards by looking above,
behind, below, & inside; put a yellow caution
tape and safety signage

Overexertion_rep Wounds, 4 2 8 Avoid overreaching and ensure appropriate 3 2 6

etetive motion laceration positioning.

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 PTW ENGR's COPY
SN:
Job Hazard Analysis & Risk Assessment Form
Section 1 - Work Information
WORK ACTIVTY DESCRIPTION JOB LOCATION

REPLACEMENT OF SEALPOT AND ITS TUBING GCGI STEAM HEADER UNIT 1

Remove old sealpot Caught in Wounds, 5 3 15 Secure hand and power tools by tying using a 4 2 8
laceration, rope/holster/case; ensure scaffolding to have
burned freom a toeboard; stay away from the line of fire;
metal chips put a yellow caution tape and safety signage;
designate a person to oversee the barricaded
area and warn anyone to keep away from the
barricade

Clear the sorroundings strike against Wounds, 4 3 12 Conduct housekeeping; remove object with 3 2 6
sharp or jagged laceration sharp or jagged edges; clear the area; check
edges surrounding hazards by looking above,
behind, below, & inside; Wear hard hat, Safety
Glass, Safety shoes, Cotton gloves or leather
gloves.

Install the new sealpot
Contact with Electric 4 3 12 Perform lockout/tagout and ensure zero 3 3 9
electricity shock/burned energy state; Do not touch any wire with bare
hands - treat any wire as live unless tested;
Verify panel meter readings; Install ground
wires; Wear adequate PPEs as identified in
the JHA (such as electrical gloves, hard hat
faceshield, arc rated gloves, safety shoes,
etc.); short circuit capacitor terminals; use
Ground Fault Circuit Interrupter; rubber mat

Install the new tubings
Strike against Wound, 3 2 6 Place end cap of protruding rebars, pipes and 3 1 3
stationary objects laceration the like; Conduct housekeeping; remove
protruding object; clear the area; check
surrounding hazards by looking above,
behind, below, & inside; put a yellow caution
tape and safety signage

Housekeeping Overexertion_Lift Back pain, 3 2 6 Lift w/ your legs, load must be closed to the 3 1 3
ing Damage to spinal body, Use trolley if available, Do not lift heavy
chord load or avoid manual handling

strike against Wounds, 4 3 12 Conduct housekeeping; remove object with 3 2 6

sharp or jagged laceration sharp or jagged edges; clear the area; check
edges surrounding hazards by looking above,
behind, below, & inside; Wear hard hat, Safety
Glass, Safety shoes, Cotton gloves or leather
gloves.

NOTE: Refer to the Risk Matrix table for estimating the C and L (C Consequence, L Likelihood )
Section 3 - Additional Recommendations Section 4 JHA & RA development Team
PTW Applicant RE POVADORA

PTW Holder AD GORDO JR.

Area Owner TGPP

Section 5 - Acceptance & Approvals
PTW Issuer ER DAGLE

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 PTW ENGR's COPY
SN:
Job Hazard Analysis & Risk Assessment Form
Section 1 - Work Information
WORK ACTIVTY DESCRIPTION JOB LOCATION

REPLACEMENT OF SEALPOT AND ITS TUBING GCGI STEAM HEADER UNIT 1

PTW Approver RP ABLEN

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 HAZARD EVALUATION GUIDE SN:

Section 2 Tool for Identifying the Primary Sources of Potential Job Hazards Section 3 Categories for Control Measures
Hazard Analysis Consideration General Hazard Examples of Specific Hazards Pertinent to Control Measure Category Specific Control Examples
Category Category
Can worker be struck by anything? Struck by (SB) Moving objects Elimination or Substitution Use of lead free, non-toxic paint
Falling material Use a trolley instead of manual handling
Can worker strike against anything? Strike against (SA) Stationary or moving objects Engineering controls Ventilation
Protruding objects Barricades
Sharp or jagged edges Administrative controls No Smoking Policy
Can worker be caught between anything? Caught between (CB) Moving and/or stationary objects Rotating personnel
Pinch points Job frequency reduction
Can worker come into contact with any energy Contact with (CW) Electricity Safe work practice or procedure Confined Space Entry Procedure
source or hazardous material? Chemicals Lock Out/Tag Out Procedure
Extreme Heat/Cold Gas Testing Procedure
Can worker by contacted by any energy source Contacted by (CBy) Splashing chemicals Personal protective equipment Hard hats; safety shoes; safety glasses
or hazardous material? Animals and Insects Respirators
Arcing electricity Chemical Protective Clothing
Can worker be caught on anything? Caught on (CO) Moving parts Fall protection harness
Sharp or jagged edges
Protruding objects
Can worker be caught in anything? Caught in (CI) Settling material
Falling material
Moving parts
Can worker fall to same level? Fall, same level (FS) Slip/trip/fall
Poor footing
Wet surfaces
Can worker fall to level below? Fall to below (FB) Unstable footing
Unprotected platforms
Is there a possibility of overexertion? Overexertion (O)
Pulling / Pushing
Repetitive motion
Can worker be surrounded & overcome by a Engulfment (En) Cave-in
granular substance such as soil, sand, or Wall collapse
submerged in a liquid such as water or a Landslide
chemical?

Is there a possibility of exposure to hazardous Exposure (Ex) Chemical vapors; toxic gases
chemicals or temperatures or other Oxygen Deficiency
environmental conditions? Excessive noise
Radiation
Extreme weather conditions

Page 5 of 8
Is there a potential to spill, leak, or discharge Release to (RT) Ground/Water contamination
hazardous materials?

Frequency of Likelihood of
Probability
Occurrence Happening RISK MATRIX SN:

Can occur Almost certain 5 10 15 20 25

5 81% - 100% daily/ weekly to occur

Can occur Very likely to

4 8 12 16 20 SAFETY IMPACT
4 61% - 80% quarterly/ occur
semi-annually
LIKELIHOOD

Can happen in Likely to occur 3 6 9 12 15 ENVI IMPACT

3 41% - 60% 1-2 years

2 4 6 8 10
Rarely occurs Unlikely to
2 21% - 40% (3-5 years) occur

1 2 3 4 5
Never heard Almost no
1 1% - 20% of in the likelihod to
industry occur
Score

Medical Fatality
Treatment/ Lost Time Permanent
Physical Injuries First Aid Restricted Incident Disability (Single/
Duty Multiple)

Environmental Damage See below.

Score 1 2 3 4 5
CONSEQUENCE

Page 6 of 8
 PTW HOLDER's COPY

Pre Task Safety Meeting SN:

Attachment O

Section 1 Work Information

Specific Work for the day

MAIN CONTRACTOR: WORK PARTY: EVC PTW APPLICANT: RE POVADORA

Section 2 - Applicable Life Saving Rules

Section 3 - Specific Hazards and its controls (for the day)

Section 4 - General Guide

1. Discuss requirements stated in the PTW, Associated Clearances, and JHA & RA.
2. Workers should be trained, competent, and certified for their assigned tasks.
3. When using specialized tools/equipment, be sure to review its safe operating procedure.
4. Extension cords should be of the double insulation type, should have no splice points in between its length, should be connected to a
GFCI, and should be able to carry the continuous load current.
5. Before tapping to the facility's power outlets, ask permission from authorized facility personnel.
6. Secure tools from falling if working at heights.
7. Never assume. When in doubt, ASK.
Section 5 - Work Party Statement of Acceptance

The requirements for the safe performance of this task/ job have been explained to us. Having clearly understood the requirements, we hereby give our
unconditional commitment to comply and adhere to them so we can do and complete the task/job in the safest and most efficient manner.

TIME - IN TIME OUT

Name Position Signature Date Time Name Position Signature Date Time

1 APPLIC 1 APPLIC

2 2

3 3
4 4

5 5

6 6
7 7

8 8
9 9
10 10
11 11

12 12
13 13

14 14
15 15

16 16
17 17

18 18
19 19
20 20

Pre Task Safety Meeting Conducted by (PTW Applicant) : [Name & Signature]
Section 6 - Housekeeping Section 7 - Stop Work Instructions
This is to confirm that housekeeping was done prior leaving the workplace.
The work activity shall be stopped when: (1) An alarm is sounded; or (2) An incident, accident or near
miss occurs; or (3) The Scope of Work changes; or (4) New hazards develop; or (5) The validity of the
Permit expires.
When the Emergency Alarm sounds, all work shall stop and any motorized equipment shutdown. All
personnel will exit the work area in a safe manner and report to their assigned assembly point unless
instructed otherwise.
Verified by: PTW Holder
 PTW HOLDER's COPY

HOT WORK CLEARANCE SN:

Attachment E

Section 1 - Work Information Section 4 - Work Area Preparation ...continued

Area Owner TGPP Y N NA
CMMS Work Order No./Contract No.: 51794 Sight glass flushed and blinded?
PTW Holder AD GORDO JR. All connecting/supply lines blinded?
PTW Applicant: RE POVADORA Energy sources isolated, locked & tagged?
Work Scope: Welding machine grounded to work?

Potential for flammable or explosive residue?

REPLACEMENT OF SEALPOT AND ITS TUBING Gas cylinders secured and upright?
Flammable/combustible materials removed?
Facility/Equipment Description: Materials that can not be removed is wet down

Combustible floors protected?

SEALPOT & TUBING
Holes and cracks covered?

Equipment Number: SH-U1 Radiation source isolated?

Job Location & Work Boundaries (indicate specific work site and physical Hot Work equipment in good condition?
limits; attach sketch if needed): Job site clear of trash & combustibles?

Gas tanks/cylinders moved 15m away?

GCGI STEAM HEADER UNIT 1 Correct CB rating for hot work equipment?

Additional Instruction or Precautions:

Material contained in the space/vessel/equipment when Service:
Name of material, chemical or substance:

Name & Signature of Firewatcher

Section 2 - Hot Work Particulars & Hazard Assessment Section 5 - Supplementary Attachment
Y N
Hot work involves the following activities: (check all that apply) Gas testing Record (Required where there is potential
presence of chemicals, flammable liquids and gas)
Grinding Hot Tapping Open Flame Works
Brazing Heat Treatment Other (specify)
Burning Soldering Section 6 - Approvals & Acceptance
Chipping Torch Cutting Date Time Name /Signature
Arc Welding Grift Blasting PTW Issuer ER DAGLE
Gas Welding Sand Blasting PTW Approver RP ABLEN
PTW Holder AD GORDO JR.
Hazard Assessment PTW Applicant RE POVADORA
Will the Hot Work be performed inside Classified Areas?
Will the Hot Work be performed where wall/floor openings Section 7 - Clearance Cancellation
expose combustibles in adjacent areas? Date Time Name /Signature
Will fire alarms or suppression systems be disabled during Cancelled by:
the hot work? Returned by:
State Reasons for Cancellation:
Is MSDS available? Y N
Will the work generate hazwaste? Y N
Toxic Y N
Reactive Y N Section 8 - Work Completion and Close Out
Flammable Y N Y N N/A
Corrosive Y N The fire watcher(s) stayed for 30 minutes
after hot work?
Section 3 - Safety Requirements Is the job complete?
Fire watcher(s) deployed SCBA Has the work area been restored
Fire extinguishers Evacuation & assembly point and cleaned up?
Two Way Radio Continuous forced ventilation Have all tools and equipment been removed?
Fall Protection Supplied Air Respirator Have all PTW documents been returned?
Gas badge Charge fire hose when req'd. All members of the work party are
Rescue Team required Respirator - Type accounted for?
Fire blanket/spark Ear Protection
containment Surrounding sewer/drain Clearance Closed by: Date Time Name / Signature

Work Area isolated with within 15 meters covered PTW Applicant
signs/barriers Welding goggles/gloves/apron PTW Holder
Others: PTW Issuer
PTW Approver
Section 4 - Work Area Preparation
Y N NA Section 9 - Conditions of Hot Work Clearance (HOW)
Equipment & lines depressurized? PTW Holder confirms that the PTW Applicant has complete
Equipment & lines flushed? understanding of all the conditions of this Clearance.
Equipment & lines drained/emptied? After accounting for all members of working party, the PTW
Equipment & lines water washed? Applicant shall return all PTW documents to the PTW Holder
Equipment & lines chemical washed? daily at the end of the work day or work shift, regardless of
Equipment & lines steamed out? whether the work is completed or not.
Lines/spool pieces removed HW Clearance shall be renewed daily.