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MSCP01/Ch16/Rev1 01/Page 27

ANNEX 16.2.1

SANCTION-TO-TEST

ELECTRICAL HIGH VOLTAGE SYSTEMS

(OVER 1000 VOLTS)

Note (i): The Authorising Officer should indicate the sections applicable by

ticks in the left hand boxes next to headings, deleting any subheading notapplicable.

Note (ii):The Authorising Officer should insert the appropriate details when

the Sections for Other Work or Additional precautions are used.

Note (iii):The Authorised Person should tick each applicable righthand box

as they make their check.

Note (iv):This Sanction-to-Test contains 6 sections.

SECTION A Scope of WorkLocationLocationLocationLocationLocation (designation of space)...................................................................................................

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PlantPlantPlantPlantPlant ApparApparApparApparApparatus /Identifatus /Identifatus /Identifatus /Identifatus /Identificationicationicationicationication

(designation of machinery / equipment) ......................... ........................... ........................... ..

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WWWWWoror

ororork to be donek to be done

k to be donek to be donek to be done (description) .................................................................................................

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PPPPPererererermit issued tomit issued tomit issued tomit issued tomit issued to (name of person carrying out work or in charge of the

work party) ........................... ............................. ............................ ............................. ..............................

Section B Check List / Isolation Data

Has a risk assessment of the proposed work been carried out?

The aboThe aboThe aboThe aboThe abovvvvve appare appare appare appare apparatus is dead and has been isolated from the system atatus is dead and has been isolated from the system atatus is dead and has been isolated from the system atatus is dead and has been isolated from the system atatus is dead and has been isolated from the system atthe fthe fthe fthe fthe folloolloolloolloollowing pointswing pointswing pointswing pointswing points (Description) ...........................................................................................

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Circuit Main EarCircuit Main EarCircuit Main EarCircuit Main EarCircuit Main Earths haths haths haths haths havvvvve been applied to the equipment at thee been applied to the equipment at thee been applied to the equipment at thee been applied to the equipment at thee been applied to the equipment at the

fffffolloolloolloolloollowing points.wing points.wing points.wing points.wing points.

(These Ear(These Ear(These Ear(These Ear(These Earths maths maths maths maths may be remoy be remoy be remoy be remoy be removvvvved and replaced to yed and replaced to yed and replaced to yed and replaced to yed and replaced to your instrour instrour instrour instrour instructions)uctions)uctions)uctions)uctions)

(Description) .......................... .............................. .............................. .............................. ........................

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SafSafSafSafSafety Locksety Locksety Locksety Locksety Locks

(Detail location fitted and identify lock set) ............................. ............................ .................

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Additional Precautions to aAdditional Precautions to aAdditional Precautions to aAdditional Precautions to aAdditional Precautions to avvvvvoid danger haoid danger haoid danger haoid danger haoid danger havvvvve been take been take been take been take been taken ben ben ben ben byyyyy

(Description) ............................ .............................. ............................. ............................... .....................

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Caution/Danger notices have been applied at all points of isolation, and

Safety Signs appropriately positioned.

TREATREATREATREATREATTTTT ALL OALL OALL OALL OALL OTHERTHERTHERTHERTHER APPAPPAPPAPPAPPARAARAARAARAARATUSTUSTUSTUSTUS ANDANDANDANDAND AREASAREASAREASAREASAREAS AS DAS DAS DAS DAS DANGERANGERANGERANGERANGEROUSOUSOUSOUSOUS

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SECTION C Authorising of Sanction-to-Test

PPPPPerererereriod of validity of sanction-to-testiod of validity of sanction-to-testiod of validity of sanction-to-testiod of validity of sanction-to-testiod of validity o f sanct ion-to-test (should not exceed 24 hours).... hours

I hereby declare that the above equipment is dead and isolated from all live

conductors and connected to earth.

AuthorAuthorAuthorAuthorAuthorising perising perising perising perising personsonsonsonson

(Name) ........................................................ (Signature) ..................................................................

(Time) ........................................................... (Date) ...........................................................................

SECTION D Receipt of Sanction-to-Test

I accept responsibility for carrying out the work on the apparatus detailed

on this sanction-to-test and no attempt will be made by me or people

under my charge to work on any other apparatus or in any other area.

I am satisfied that all precautions have been taken and that safetyarrangements will be maintained for the duration of the work.

SafSafSafSafSafety Key Noety Key Noety Key Noety Key Noety Key No ............................... Received* /Applied*

Competent perCompetent perCompetent perCompetent perCompetent personsonsonsonson

(Name) ........................................................ (Signature) ..................................................................

(Time) ........................................................... (Date) ...........................................................................

Note: After signing the receipt, this sanction-to-test should be retained by

the person in charge at the place where the work is being carried out untilwork is complete and the clearance section signed

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SECTION E Clearance of Sanction-to-Test

The work for which this sanction-to-test was issued is now suspended* /

completed* and all people under my charge have been withdrawn and

warned that it is no longer safe to work on the apparatus detailed in this

permit to work.

All work equipment, tools, test instruments etc have been removed.

Competent perCompetent perCompetent perCompetent perCompetent personsonsonsonson

(Name) ........................................................ (Signature) ..................................................................

(Time) ........................................................... (Date) ...........................................................................


SECTION F Cancellation of Sanction-to-Test

This Sanction-to-Test is cancelled.

AuthorAuthorAuthorAuthorAuthorising Pising Pising Pising Pising Pererererersonsonsonsonson

(Name) ........................................................ (Signature) ..................................................................

(Time) ........................................................... (Date) ...........................................................................


* Delete words not applicable and where appropriate state:

The wThe wThe wThe wThe wororororork is complete* / incomplete* as fk is complete* / incomplete* as fk is complete* / incomplete* as fk is complete* / incomplete* as fk is complete* / incomplete* as folloolloolloolloollows:ws:ws:ws:ws:(descr(descr(descr(descr(description)iption)iption)iption)iption)

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