44 Formulir Ijin Kerja Penggalian

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EXCAVATION PERMIT IJIN PENGGALIAN NO. ……. DATE TANGGAL PURPOSE MAKSUD

: _________________

LOCATION : ______________ LOKASI : __________________________________________________

The area detailed by sketch below has been thoroughly searched by way of facility drawings. Lokasi penggalian yang dijelaskan di bawah telah diperiksa secara melalui gambar denah fasilitas. The following excavation hazards are noted: Berikut bahaya-bahaya yang terdapat pada pekerjaan penggalian: 1. 2 3 4 Precautions required prior to excavation are: Tindakan pencegahan sebelum penggalian: 1. Limited excavation digging Pengamanan daerah penggalian 2. Hand shovel digging required Alat penggali tangan disediakan 3. Spotter to identify hazards Mengidentifikasi potensi bahaya 4. Electrical or other isolations Isolasi peralatan listrik/lainnya 5. Others Lain-lain

( ) ( ) ( ) ( ) ( ) Tick (X) applicable boxes Beri tanda (X)

SKETCH OF LOCATION DETAILS RINCIAN LOKASI PENGGALIAN ELECTRICAL/ MAINTENANCE SUPERVISOR : _________________________________ EXCAVATION SUPERVISOR : _______________________________________________ FACILITY SUPERVISOR

: _______________________________________________ SUMMARY OF WORK COMPLETED PENYELESAIAN PEKERJAAN

SIGN-OFF SIGNATURE : _________________________________________________ Tanda Tangan