COLD WORK PERMIT PERMIT SECTION 1 - WORK DESCRIPTION NameiSign: Month: A. Identify Plant/facilty area: B. Exact work location: C. Work to be done... D. Equipment to be used at the site -... SECTION 2-HAZARD IDENTIFICATION & CONTROL A. Identify and attach any supplementary forms required to perform/control the work: Dob Safety Analysis Cl Hydro test procedure(s) G Excavation Checklist Olsolation plan 1D Gas test records CBB lst }. Energy Types: Ci Hydrocarbonigasisteam/chemicals Potential energy (spring loaded, gravity) Dother . Isolation Methods): COLocked switch/breaker 1 Double biock & bleed U Single block & bleed ). Potential Exposures: OHigh noise level O Radioactive materials 0 Other. . Protective Equipment: O Personal H2S monitor OFRC 1 Barricades/waming signs 1 Gogglesiface shield U Respiratory protection (Explain further in Additional Safety Precautions below) F. Standby Man Needed’) Badge No. .. G. Tool Box Meeting Conducted: Yes) Nol] No. of attendants: List any Additional Safety Precautions: Mechanical 1 Automated extinguishing systems Mechanical biock DBlinding Other... Hydrogen Sulfide (H:S) 1D Temperature Bother IN AN EMERGENCY: Critical Lift Pian Other. O Electrical S Hydraulicipneumatic 1D Block valve G Disconnect Flammable liquids/gases Ci Hazardous\toxic materials ‘Chemical suivcoveralls Fall protection SECTION 3-GAS TESTING/MONITORING Periodic monitoring required: Yes CINoLIIf yes, attach a supplemental form. Gas testing fre quency: ONLY CERTIFIED GAS TESTERS PERFORM GAS TESTS LEL (%) | H2S(ppm) Other gases (namo/Value) Badge No. | Signature Initial Test Renewed SECTION 4-PERMIT AUTHORIZATION & CLOSURE Signature: Position: Date:. Time: Receiver Org Issuer Org.: Countersignature(s) if applicable PERT | Badge Ne Cont No oa} cr ‘Senate Open This permit is renewed Date: ‘Courtrignrs) note af permit onawal Renewal) [This permitis renewed Date: THAVE INSPECTED THE WORK SITE AND CONFIRM THAT I ClosedY N'IN/A N/A. Is the correct type of permit(s) issued for the work? Is the systam/equipment propery isolated and locked out? Did all workers apply their personal lock? Have the Job Safety Analysis and other applicable supplementary forms been ‘communicated to the work crew? Has the systen/equipment been depressurized, drained andior purged before opening it? ‘Are weather conditions (eg., wind speed) acceptable to perform work? Has the potential for releasing flammable liquids and gases been controlled? ‘Are slip and trip hazards controlled? ‘Are all ignition sources eliminated or controlled? Does the work crew have the correct tools/equipment for the job? Ave they in good condition? oes the fire waich have firefighting equipment readily available and know how to use the equipment?” Do personnel have the proper certifications to perform the activity andior operate the ‘equipment? Is the equipment’s inspection sticker valid? Have all requirements for wor (le. Fall protection) been applied? at heights | controlled? | ttthe work may impact others nearby, or vice Has the potential for exposure to high noise level, H2S, hydrocarbons, asbestos, hazardous ‘chemicals or radioactive materials been Is the correct Personal Protective Equipment (PPE) available for use by personnel? versa, have the work crews discussed their activities with each other (ie. Simuitaneous ‘operations [SIMOPS})? Is the scaffold tag completed correctly, signed ‘and with a valid inspection date? Is there an emergency contingency plan in place 10 respond to the work being performed? Has the potential for contact with sharp objects, rotating equipment, hot/cold surfaces or live electricity been eliminated? Does the work crew know what to do in the event of an emergency, such as evacuation routes, location of emergency equipment and ‘where assembly areas are located? ‘Any 'N' (NO) answers above shall initiate a "STOP" point where the issuer and Receiver are to analyze the hazard(s) and develop methods to adequately control the hazard(s) and list the additional precautions on the permit. Signature: Issuer or Designated Representative ‘Any roading above 0% LEL. Combustible 5% LEL-10% LEL No hot work allowed Breathing apparatus must be used Gases/Vapors 10% LEL or Above ‘No work (or confined space Entry) allowed 10 PPM or above Breathing apparatus must be used Hydrogen Sulfide (H2S) ig ppy- 400 ppm _|_ Division head must sign the Permit 400 PPM or above ‘No work (or confined space Entry) allowed ‘Breathing apparatus must be used and Division head must 1 Less than 20.0% Oxygen (02) sign the Permit Above 23.5% No work allowed 35 PPM-1000 PPM | Breathing apparatus must be used Carbon Monoxide (CO) 1000 PPM or above No confined space entry allowed DIVERSIFIED LINES PETROLEUM SERVICES.cps DLPS SECTION 1 - WORK DESCRIPTION Name/Sign: Month: A. Identify Planv/facility area: B. Exact work location: C. Work to be done: D. Equipment to be used at the site : SECTION 2-HAZARD IDENTIFICATION & CONTROL ‘A. Identify and attach any supplementary forms required to perform/control the work: C Confined space Entry Plan (Mandatory) a Confined a sad roa (Mandatory) Job Safety Analysis 35 test records isolation plan Cindi Cexcavation Checklist CiHydro test procedure(s) OOther. B. Energy Types: Hydrocarbon/gas/steam/chemicals []Mechanical CO Electrical Oydraulicrpneumatic Potential eneray (spring loaded, gravity) Automated extinguishing systems) Other. ©. Isolation Methods): Locked switchibreaker ]Mechanical block Block valve GBtinding [Double block & bleed Single block & bleed Disconnect Other. Positive isolation (blind or disconnect) shall be used for al piping connections to the ‘confined space. D. Potential Exposures: High noise level Hydrogen Sutfide (2s) OFlammable liquids/gases Hazardousltoxic materials TI Radioactive materials" Temperature. E, Protective Equipment: CiPersonal 2S montor— CIFRC 2 Gogglesstace shield Ci Chemical suivcoveralls, C1Fall protection DBarricades/warning signs 1D Mechanical Ventiation/blower D Respiratory protection (Explain further in Additional Safety Precautions below) F. Confined Space Entry Supervisor(CSES)L} Badge No, ---------memm G. Confined Space Entry standby Man_] Badge No. - H. List any Additional Safety Precautions: CONFINED SPACE ENTRY PERMIT Manpower PERMIT # Department: _. Year. Duration ‘SECTION 3-GAS TESTING/MONITORING Periodic monitoring required: Yes No If yes, attach a supplemental form. Gas testing frequency: Additional gas tests required prior to entry, ater breaks interruption of work, if site conditions ‘change, and at periodic intervals (as required). Record below or use a supplemental form ONLY CERTIFIED GAS TESTERS PERFORM GAS TESTS Other gases Let.) | Hisioom | ones | Qhergeses, | wadgen. | Sinatwe Initial Test Renewed Additional Additional ‘SECTION 4-PERMIT AUTHORIZATION & CLOSURE Signature: Positio _ Time: Receiver Org. Issuer Org: PERMIT | Badge No. | Cert. No. Badge No. | Cert. No. Signature: Open This permitis renewed Date: Duration: Open This permitis renewed Date: Duration: |IMAVE INSPEGTED THE WORK SITE AND CONFIRM THAT IT HAS BEEN RETURNED TO A SAFE CONDITION ClosedPERMIT INFORMATION HAZARD ANALYSIS CHECK LIST Y_[NN/A y_[N|N/A Se a a ee isthe system/equpment properly bolted andlocked out? Did all workers eee eo apply thelr personal lock? Have the Job Safety Analysis and other applicable supplementary forms Has the systemequipment been depressurized, drained andlor purged before been communicated tothe work crew? opening it? ‘Are woathor conditons (8g, wind speed) acceptable to perform work? Has the potential for releasing flammable iquids and gases been controlled? ‘Are weather conditions (69, wiad speed) acsaplable fo perfor work? ‘Avo all ignition sources eliminated or controlled? er Does the fre watch have fhefighting equipment readily avalable and know how ee Se a ey touse the equipment? Do personnel eve the proper certifications to perform the activity andor Has the potential for exposure to high noise level, H2S, rydrocarbons, asbestos, operate the ecupment? hazardous chemicals oF radioactive materials been contraled? DE ay Is the corect Personal Protectve Equipment (PPE) avalablefor use Is the equipment’ inspection sticker valid? i eeleores Have al requiremenis for working at heighs (i. Fall protection) been The work may impact others nearby, or Woe versa, have ihe work crews applied? discussed their actives with each other (e. Smultanecusoperations [SIMOPS)? Is the scaffold fag completed correctly, signed and with a valid Is there an emergency contingency plan in place to respond to the work being inspection date? performed? Has the potental for contact with sharp objects, rotating equipment, Doss the work crew krw wit to do Bie event of an enuerpancy; such as FGIEEI STRSEae Ine Ste Te eit evacuation routes, locaton of emergency equpment and where assembly areas list the additional precautions on the permit Signature: Issuer or Designates Representative Receiver, ‘Any 'N’ (NO) answers above shall initiate a "STOP" point where the issuer and Receiver are to analyze the hazard(s) anddevelop methods to adequately control the hazard(s) and GAS TEST INFORMATION TABLE Combustible Gases/Vapors Hydrogen Sulfide (H2S) Oxygen (02) ‘Any reading above 0% LEL No hot work allowed 5% LEL-10% LEL Breathing apparatus must be used 10% LEL or Above No work (or confined space Entry) allowed 10 PPM or above Breathing apparatus must be used 10 PPM - 100 PPM Division head must sign the Permit 100 PPM or above No work (or confined space Entry) allowed Less than 20.0% Breathing apparatus must be used and Division head must sign the Permit ‘Above 23.5% No work allowed 36 PPM-1000 PPM Breathing apparatus must be used 1000 PPM or above No confined space entry allowed DIVERSIFIED LINES PETROLEUM SERVICESoe Op HOT WORK PERMIT —_—PERMIT# oars a A. Anty Plant are. 18. Exact work cat 6. Work tobe dane . Eauipment obo uso at se ‘SECTION 2-HAZARD IDENTIFICATION & CONTROL ‘A. Identify and attach any supplementary forms required to performfcontrol the work: (Cob Safety Analysis Hyer test procecce(s|Ciritical Lit Plan Other ennnnnenn excavation Checkist Csotton Pian (CGas test records) [Bind Ist B. Energy Types: CHydocartonigatsteamichemica's Mechanical 1 Electrical C1 thet mn Potential energy (pring loaded, gravity) Automatod extinguishing systomel1Hydrauclpreumatc . Isolation Methoa(s): 1D Locked swttvreaker Mechanical back Block vate C) Sige block & bleed Ci ooubieticek& teed ClBindng —ClDisconnact Comer. . Potential Exposures: Di tigh noisetever Cyanogen Sutde (125) CQlammableiqusigases [othe C Radoactvematels Cemperatie Dhezardoushoxie tera E. Protective Equipment: personal 2s monitor C) Goggestce shield C)Fall protectin 1D aricadesvaming sens CIChemial suteoverats re ‘Corespratry protcton Expian futher in Adioral Safty Prcauton below) Fire Protection Methods: Fre oxtnguishorLiFre menitthose Clea woted Fre Sairlshilds 6. Coveriwater seal ll owers within 23 m (7 ft) of tho Hot Work area) H.Standby Man needed Badge No. Fee Watch nooded [List any Additonal Safety Precautions: aa one Bago No. INAN EMERGENCY: Ciseo anacnes ‘SECTION 3-GAS TESTING/MONITORING (Gas tating equency: Periodic montorng required: Yes(INeCIM yes, attach a supplemental fom INLY CERTIFIED GAS TESTERS PERFORM GAS TEST! TEL CH | H2Sippm)] 02(%) [Other | Badge No Snare Int Test Renewed ‘SECTION 4-PERMIT AUTHORIZATION & CLOSURE S81: ennnnnnenn POSER nnn OFF Badge Ne Signature Postion: on: facie No Resse er Oo PERWT | BsdgeNo] Cer. No | Sgnatie age No] Cr. No. ‘Sonate pen Ths permits reve Tin ocacnsnsenone | COBRARAR AES or BE ane Closed evalep metrods to adequately conrl the hazae(s ar ist | the ational precautions onthe peri |e the covet type of pam isued forthe ‘won ave the Job Safety Anais and other sppicbiesplerentany onrs boon [Grvricaed ote work cow? ‘Are weather coneion 9. wisps) sczaplable to partook? 2 sp arti hazards corvta?> Feauipment for he ob? Ae hay in goo éondton? ‘Do personnal have the prope ceriicatos to ‘prom the acivly andor erate te Have all requirments or working ot highs “teal poten) beon applied? Is th scafling completed corety signed Has he potential fr contact with sharp bcs rotting qupmont hoveld surfaces "se ajtomiequpment prope nite ond portal ck? as ne systomloqupmert bean Seprenied aod dr pred before as he portal or releasing farmae ide ana gases boon contoted? “re algntion ourcos alate’ ‘econo? ‘oes the fre waleh have ean ‘qugmenreaty aati sr kaw ht (Sotho oqupmect? a the potential fr expo fo ih ni level H2S,hyrccatbons, asbestos, hazardous athe corel Persea Prolectve Equipment (PE) avalabe for se by persernel”, Isthere an emerganoyconingeney pan The wok may mpaat ters noooy,ovice versa nok crows dacused thee eis wh each che fe. Simutanooss operations [SIMOPS))? luce torespond ie Be work bing permed leewar or Designated Representative = eco.Op HOT WORK PERMIT DLps PERMIT AUTHORIZATION & CLOSURE ‘Signature: The issuer and receiver complete and sign the ont ofthe permit (section 4) once the hazard analysis has been completed and al spectied hazard conols aren place, requires gas tet recorded, ane supplemental forms alached. Adtional signature are required for extended permit or when gas {est are at vel indicated nthe gas test information table ‘Countersignature: The issuer must obtain the approval and signature of other organization whose operation willbe affected by the work Renewed Permit: Required signature of the issuer and receiver coming on shift, nd notification to all countersigning organizations, Extended Permit: Required signature ofthe division head (or above) of both the issuing and receiving organization, Closed Permit: The issuer and recelver must sign the work permit after completion of the work or when the permit duration has expired, For addition: formation on the Saudi Aramco Work Permit System, Refer to Gl. 2.100 GAS TEST INFORMATION TABLE ‘ay reading above 0% LEL No hot work alowed Combustible Gases/Vapors [5% LeL-10% LeL Breathing apparatus must be vsed 10% LEL oF Above No work (or confined space Entry) allowed 10 PPM or above Breathing apparalus must be used Hydrogen Sulfide (H2S)_— [10 pp 100 PPM Division head must sign the Perit 100 PPM or above ‘No work (or confined space Entry) allowed % Beaty pts mated One a ota Oxygen (02) Less than 20.04 = ES ‘Above 23.5% No work alowed i resting sopartia rut bowed Carbon Monoxide (CO) Se eee eee whee 1000 PPM or above Ti cond apace ent alowed In an Emergency Stop Work Authority 1. Stop Work 2.bia‘ott 3. Move to a Sate Area 4 Intiate response action plan EE il Dhahran Area | (013) 872-0911 | Dhahran bps EDL ay Saat (013) 880-0911 el STOP (013) 578-0911 | Shaybah (013) 875.0911 | Turait Ifi's unsafe, stop work and (013) 877-0911 | AbJami report it to your supervisor. ‘Souther Area | (013) 572-0911 | Abaaiq (013) 576-0911 | Udailyah You are empowered to stop work immediately if you observe (013) 577-0911 | Mubarraz (013) 862-0911 | Shedgum (013) 873-0911 | south Ghawar damage equipment, or harm the environment, immediately an unsafe job that has the potential to injure personnel (073) 376.0971 report your concems tothe individual involved, as well as Saudi (013) 379.0911 | Tanajib (013) 679-0911 | Manifah (013) 673-0911 | khursaniyah (013) 677-0011 (013) 678.0911 Norther Area ‘Aramco supervisory personnel. Rastanura Central Region | (011) 285-0011 | Riyadh (013) 574.0911 | Pump Station Be Safe Hotline (013) 574-0911 | Khurais (013) 574.0911 | Hawta Your anonymous and secure channel to report (013) 574.0011 unresolved safety and security concems. Western Region, (012) 427-0911 | Jeddah & Jizan (014) 307-0911 | Yanbu (013) 872 6666 BeSafeHotline@arameco.com (014) 397-1911 | Madinah,