Pressure Testing Permit
PART A: PERMIT DETAILS: (completed by Permit Issuer/Coordinator)
Project Name: Pressure Test Plan:
Organisation Project Permit
Name: No: No:
SHEWMS Reference
Work Location:
No:
Start Finish
Start Date: / / : Finish Date: / / :
Time: Time:
Define Scope of Works to be undertaken (as per referenced SHEWMS):
PART B: WORK CONTROLS : Tick as required (completed by Permit Issuer/Coordinator)
Yes N/A Yes N/A Yes N/A
Access to test area For hydrostatic test, air / Pressure relief valve set
adequately controlled with gases vented at highest to maximum proposed
barriers, signage and points and vents then test pressure and of
other measures closed sufficient capacity
Energy Isolation Permit
System under pressure
completed and Isolations Gauge located near tester
adequately supported
in place
Capacity of test manifold,
Pressure gauges Emergency response
pressure relief valve, and
calibrated and adequate, process in place and
block / isolation valves
and certificates available understood
calibrated and adequate
All required blanks Blow down valve installed Post-test
installed to exclude for draining of test fluid depressurisation plan in
equipment not under test post-test place
Further site specific precautions to be taken:
PPE Requirements – tick as required and detail any other specific requirements
Respiratory
Safety Helmet Gloves Safety Boots Eye Protection
Protection
Coveralls High Vis Vest Ear Protection Other
PART C: PERMIT ISSUE (completed by Permit Issuer/Coordinator)
I confirm that all work control measures made to ensure the safety of those working under this Permit are in place. The work
area has been checked and it is safe for work to proceed under the conditions stated in this Permit.
Time: (24
Permit Issuer: Signature: Date: / / :
hr):
PART D: PERMIT ACCEPTANCE (completed by Permit Acceptor)
I understand and accept the conditions and precautions detailed above. I shall implement all controls and ensure personnel have
been instructed
Time: (24
Permit Acceptor: Signature: Date: / / :
hr):
PART E: PERMIT CANCELLATION (completed by Permit Acceptor)
I confirm that all work for which this Permit was issued has been completed, all safety devices and isolations have been removed
and the workplace has been inspected and left in a clean and safe condition
Time (24
Permit Acceptor: Signature Date: / / :
hr):
PART F: PERMIT CLOSURE (completed by Permit Issuer/Coordinator)
I confirm that all work for which this Permit was issued has been completed and verify the Permit has been cancelled by the
Permit Acceptor. All personal safety control precautions as detailed in this Permit have been removed including all safety devices
and isolations and the workplace has been inspected and left in a clean and safe condition
Time: (24
Permit Issuer: Signature: Date: / / :
hr):
Title: Pressure Testing Permit Date Published: 18/09/2012 Page 1 of 2
ID: 149445 Version: 1
Project Management System / N5012 - Uncontrolled Document when Printed
SH16 Causeway Alliance http://ourway.lc.local/index.htm?pmsId=10972
PART G: PERMIT ACCEPTANCE (for use by the Permit Acceptor to record persons working under this Permit to
Work)
A person required to work under this Permit To Work (PTW) must comply with \ the following instructions:
1. Ensure you understand the scope of the work activity and your role / tasks.
2. Ensure you have read, and/or have had explained to you and understand the requirements of the SHEWMS
and any associated Permits. Ask questions if you are unsure and report any concerns / issues immediately.
3. At the start of each working shift, ensure the Permit Acceptor has had the Permit revalidated and obtained
permission to commence work.
4. Notify the Permit Acceptor immediately if you become aware of a new hazard or change in conditions while
performing the works.
PRINT NAME DATE TIME (24HR) SIGNATURE
PART H: PERMIT TO WORK TRANSFER AND RE-VALIDATION (required where PTW has expired and is revalidated, or
responsibility is transferred to another Permit Acceptor)
As Permit Issuer / Coordinator: I confirm that all work control measures made to ensure the safety of those working under
this PTW remain in place. The work area has been checked and it is safe for work to continue under the conditions stated in
this PTW.
As Releasing Permit Acceptor: I confirm that all work for which this PTW was issued has been completed for the shift, all
safety devices and isolations have been removed and the workplace has been inspected and left in a clean and safe condition.
AS NEW PERMIT ACCEPTOR: I confirm and accept that conditions as stated in this PTW shall continue to be strictly adhered
to during the next shift and all persons under my control will be advised accordingly.
NOTE: A Permit can only be revalidated for a maximum of six shifts following the initial issue; after that a new Permit must be
requested. Where a Permit is required for more than six shifts, special arrangements must be made with the Permit Issuer and
Project Director / Manager.
TRANSFER / RE- SIGNATURES
RE-VALIDATED PERMIT
VALIDATION FOR NEXT
TO WORK EXPIRES (Initial signatures on Permit to Work)
SHIFT OCCURS
RELEASING
NEW PERMIT
DATE TIME (24hr) DATE TIME (24hr) PERMIT ISSUER PERMIT
ACCEPTOR
ACCEPTOR
Title: Pressure Testing Permit Date Published: 18/09/2012 Page 2 of 2
ID: 149445 Version: 1
Project Management System / N5012 - Uncontrolled Document when Printed
SH16 Causeway Alliance http://ourway.lc.local/index.htm?pmsId=10972
