Permit to work



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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

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