Permit to work

Permit to work

Permit to work number(to be completed by Rhenus)		     
Application date:	     	Date of works	     
Applicant (Company)	     	Applicant (contactperson)	     
Tel. number (applicant)	     	Tel. Number (work foreman)	     
Contractor (company)	     	Work foreman(contactperson)	     
Duration and description of Works (max 12hrs)	     

Risky activity		Explanation obliged
	Hot work	     
	Work on height	     
	Work with dangerous cargo	     
	Special hoisting activity	     
	Work on quay	     
	Work alone	     
	Work in enclosed space	     
	other, namelijk	     
Indentified risks		Explanation obliged
	fire	     
	Fall hazard	     
	noise	     
	Explosion	     
	Choking hazard	     
	Emission of dangerous goods	     
	Trapped in between objects	     
	other, namely	     
Obliged control measures*		Explanation obliged
	Means to extinguish fire	     
	Barrication	     
	PBM’s (which?)	     
	Gas measurements	     
	Fall protection	     
	Ventilation	     
	Fire watch	     
	Lock out – tag out (LoTo)	     
	other, namely	     

*Obliged control measures are decided by Rhenus. Below boxes are completed by Rhenus.

	Date and time	signature
Approval permit to work (Rhenus HSSE)	     	     
Issue permit to work (Rhenus gate employee)	     	     
Withdraw permit to work (Rhenus gate employee)	     	     
Inspection of workplace after completion of work (Rhenus gate employee)	     	     
Signature Rhenus gate employee	Signature work foreman

By signing the work foreman confirms to have identified all risks and required safety measures are taken and are enforced. After completion of work at the end of the shift the form must be returned to Rhenus gate employee. In case of calamity leave workplace behind safe and report to muster station

Rhenus Logistics B.V. Pagina van versie 1.2