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This permit relates to any work in hazardous or dangerous areas which will not involve generationof temperature cond itions likely to be of sufficient intensity to cause ignition of combustible gases,vapours or liquids in, or adjacent to, the area involved

From hours Date

To hours Date

Has enclosed space entry permit been issued? Yes / No

Description of cold work: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Personnel carrying out co ld work:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Responsible person in attendance: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Has enclosed space entry permit been issued?

1 PREPARATIONS (checked by Officer in Charge of cold work to be performed)

The equipment/pipeline has been prepared as follows:

Vented to atmosphere Yes / No

Washed Yes / No

Drained Yes / NoPurged Yes / No

Other

The equipment/pipeline has been isolated as follows:

Lines blanked Yes / No

Valves closed Yes / No

Lines disconnected Yes / No

Other

Is equipment free from:

Oil Yes / No

Gas Yes / No

H2S Yes / No

Steam Yes / No

Pressure Yes / No

Is surrounding area free from hazards? Yes / No

If work is to be performed on electrical equipment, has that equipment beenisolated?

Yes / No

C:\FORMS\02_0005.PDF MT LADON

COLD WORK PERMIT CHECK LISTCompany Forms and Check Lists

Date : 03.04.01Rev.No : 1Prep. : MGVApp. : CAPSection : 02Page : 1 of 2

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2 INFORMATION AND INSTRUCTIONS TO PERSONS CARRYING OUT COLD WORK

The following personal protection must be worn:

Equipment/p ipeline contained following material in service:

Equipment expected to contain the following hazardous material in service:

Special cond itions/precautions:

In the circumstances noted it is considered safe to proceed with this cold work.Signed :

____________________________ Master/Responsible Officer

____________________________ Person carrying out work task or in charge of cold work team

Section 3

The cold work has been completed and all persons under my supervision, materials and

equipment have been withdrawn.

Authorised person in charge: ______________________

Time: ____________________________________ Date: __________________________

GUIDANCE NOTES FOR COLD WORK PERMIT1) Starting/finishing time must not exceed the Authorised Signatories'/Responsible Officer's working

hours.

2) Specific locatin of cold work to be given.

3) Description of work to include type of equipment used.

4) This permit should be used for, but not be limited to, the following cold work:

a) Blanking/de-blankingb) Disconnecting and connecting pipeworkc) Removi ng and fitting of valves, blanks, spades or blindsd) Clean up (o il sp ills)e) Work on pumps etc.

C:\FORMS\02_0005.PDF MT LADON

COLD WORK PERMIT CHECK LISTCompany Forms and Check Lists

Date : 03.04.01Rev.No : 1Prep. : MGVApp. : CAPSection : 02Page : 2 of 2

INSTRUCTIONS :To be filled in before engaging in cold work. Check list to be kep t in Safety Officer's file Section 5 for a period of three years.