Limitation of Access No.

Key Safe No.*

Continuation Sheet No.

Form Limitation-Of-Access Version 2 – March 2012

LIMITATION-OF-ACCESS (CARBON COPY TO BE ISSUED)

1. (i) LOCATION …..……………………………………………………………………….……..………………….……………..……………….………..

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(ii) ACCESS TO……………………………………….….………….….………………………………………………………………………….….…….

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(iii) WORK TO BE DONE ……………………………………………………………………………..…………………………………………..….……...

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2. SAFETY PRECAUTIONS APPLICABLE

(i) LIMITS OF WORK, OR WORK AREA; OR OTHER PRECAUTIONS TAKEN

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(ii) PLANT AND APPARATUS……………………………………………………………..………..………………………….……………………..….…

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(iii) FURTHER PRECAUTIONS TO BE TAKEN DURING THE COURSE OF WORK OR TESTING TO AVOID SYSTEM DERIVED HAZARDS

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I have confirmed as/with§ the Control Engineer*………………………………………………………..……....that the precautions in Section 2(i) have been

carried out and that the Control Engineer will maintained them until this Limitation-Of-Access is cancelled. I certify that the precautions in Section 2 are adequate in respect of the work in Section 1.

Signed …………………………………….….………. being a Senior/Authorised Person. Time………..…….………… Date ………………………….

3. ISSUE

(i) Key Safe Key (No)* …………….…....…. (ii) Safety Lock Keys* …………..…….....….. (iii) Selected Person’s Report (No.)* ………...……………

Control Engineer agreeing to the issue of this Limitation-Of-Access*……………………………………………………………………………………………

Signed …………………………………………….. being the Senior/Authorised Person responsible for the issue of this Limitation-Of-Access. Time……..………..……… Date ……….…….………….

4. RECEIPT: I understand and accept my responsibility under this Limitation-Of-Access and acknowledge receipt of the items in Section 3. Signed ………………………………………..……….……… Name (Block Letters) …………………..……………………………………………………………..

Being a Competent Person in the employ of Firm/Dept. …………………………….…..…….. Time………..……………… Date ………….………..

*N/A IF NOT APPLICABLE §Delete words as applicable

Form Limitation-Of-Access Version 2 – March 2012

5. CLEARANCE: I certify that al persons under my charge have been withdrawn from and warned not to continue carrying out the work specified on this Limitation-Of-Access. All gear, tools and loose material have been removed and guards and access doors have been replaced, except for:-

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Signed……………………………………. being the Competent Person responsible for clearing this document

Time…………..…………… Date …………….………..

6. CANCELLATION: This Limitation-Of-Access is cancelled. I certify that all the items issued under Section 3 have been accounted for and the

Control Engineer*……………………………………..…………has been informed of the cancellation and of any restrictions on returning the

Plant/Apparatus to service.

Signed ……………………………………………………… being the Senior/Authorised Person responsible for cancelling this Limitation-Of-Access Time………..……………… Date ………….…………..

*N/A IF NOT APPLICABLE §Delete words as applicable

First Suspension Second Suspension Third Suspension

SUSPENSION (To be signed by the Competent Person in charge of the work as in Section 4 above)

I certify that the work for which this Permit-to–Work was issued has been suspended and that all persons under my charge have been withdrawn and warned that it is no longer safe to work on the Plant/Apparatus specified on this Permit.

Signed…………...……………….. Time..…………………………….. Date……………………………....

Signed…………...……………….. Time..…………………………….. Date……………………………....

Signed…………...……………….. Time..…………………………….. Date……………………………....

RE-ISSUE (To be signed by the Senior Authorised Person responsible for re-issuing this Document)

I certify that the points of Isolation (Section 2(i)) have not been disturbed and the Circuit Main Earths (Section 2(ii)) have been replaced and the work detailed in Section 1 may proceed.

Signed…………...……………….. Time..…………………………….. Date……………………………....

Signed…………...……………….. Time..…………………………….. Date……………………………....

Signed…………...……………….. Time..…………………………….. Date……………………………....

RECEIPT (To be signed by the Competent Person in charge of the work as in Section 4 above)

I declare that I accept responsibility for continuing the work on the Plant/Apparatus detailed in Section 1 on this Permit-to-Work and that no attempt will be made by me or persons under my charge to work on any other Plant/Apparatus.

Signed…………...……………….. Time..…………………………….. Date……………………………....

Signed…………...……………….. Time..…………………………….. Date……………………………....

Signed…………...……………….. Time..…………………………….. Date……………………………....

7. Working Party Control Record

Suspensions

1st 2nd 3rd

Name Date Briefing

Received

Time

On

Signature

Time

OFF

Time

ON

Time

OFF

Time

ON

Time

OFF

Time

ON

Time

Off

Signature