上锁挂牌作业许可Permit for lockout and tagout
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开始日期及时间COMMENCEMENT DATE & TIME:年Y月M日D：
计划完成日期及时间COMPLETION DATE & TIME:年Y月M日D：
□是否已经完成工作安全分析并传达给所有作业人员？（请附上）Whether the related JSA has been approved and communicated to all worker members ?（Please attach it）
2.我确认没有交叉作业涉及.I confirm that there will be no incompatible work.
3.我因此批准该项上锁挂牌作业.I hereby approve thelockout and tagoutwork.
建造经理/生产经理签字Signed by fabrication/production manager:
□是Yes□不适用N/A集体挂锁对隔离点上锁，将标牌挂在集体锁上。Use the collective padlock and tagout on it.
监护人签名Signed by watchman：；申请人签名Signed by applicant：。
第二步STEP 2：安全监管人员审核REVIEWED BY SAFETY PERSONNEL
□是Yes□不适用N/A拉警戒线限定安全区域Cordon off areas for distance of safe limits.
□是Yes□不适用N/A在所有可能进入受影响区域入口处突出显示警示板Prominent display of warning signboards at all possible access to the affected work area.
领班/第三方承包商主管签字Signed by foreman/ contractor’s supervisor:
第五步STEP 5：申请人完工通告NOTIFICATION OF WORK COMPLETION BY APPLICANT
上述上锁挂牌作业暂停/完成于The abovelockout and tagoutworkisstopped/completed on:年Y月M日D:
□是Yes□不适用N/A确认能量已隔离或去除Confirmed the energies have been isolated or removed.
□是Yes□不适用N/A个人挂锁对隔离点上锁，将标牌挂在个人锁上。Use the individual padlock and tagout on it.
我已检查确认所有安全要求已经遵照执行I have inspectedand confirm that all safety measures have beenimplemented.
安全监管人员签字Signed by safety personnel：
第三步STEP 3：建造经理/生产经理审批APPROVED BY FABRICATION/ PRODUCTION MANAGER
第一步STEP 1：领班/监督申请APPLICATION BY FOREMAN OR SUPERVISOR
我已采取措施使该区域适合上锁挂牌作业申请，在施工前我将确保落实以下措施，在施工过程中做好维持。I have taken measure to render the area safe and fit forlockout and tagoutworkapplication. I shall also ensure compliance with the under-mentioned prior to the commencement and during the work.
上锁挂牌作业许可
PERMIT FORLOCKOUT AND TAGOUT
ZHJT-MR-09/R01
隔离点数量No. of isolation point:；作业人数No. of operator:。
编号Serial No.：LT
项目PROJECT/厂房WORKSHOP:；位置LOCATION:。
作业描述DESCRIPTION OF WORK：。
申请人签字Signed by applicant：；安全监督人员签字Signed by HSE：
第一联original（白white）：现场张贴display on site;第二联duplicate（红red）申请人留存Applicant;
第三联triplicate（黄yellow）批准人留存Approver;第四联quadruplicate（蓝blue）安全人员留存HSE.
第四步STEP 4：领班/第三方承包商主管签收SIGNED BY FOREMAN/ CONTRACTOR’S SUPERVISOR
我将在作业前采取要求的安全措施，在第三步批准后负责整个作业过程的维持I shall take the safety measures as stated in step 1 prior to the commencement of the work process after the step 3 has approved and shall be responsible for maintaining them during the entire work process.
□是Yes□不适用N/A清理受影响区域所有无关人员Cl from the affected work area.
□是Yes□不适用N/A安排专人现场监控Assign responsible personnel to supervise the operation.
1.我确认相关影响区域已执行了彻底的检查及合理评估，所有安全措施已经采取Iconfirm that a thorough inspection and proper assessment ofaffectedarea have been carried out all the necessary safety measure have been taken.
计划完成日期及时间COMPLETION DATE & TIME:年Y月M日D：
□是否已经完成工作安全分析并传达给所有作业人员？（请附上）Whether the related JSA has been approved and communicated to all worker members ?（Please attach it）
2.我确认没有交叉作业涉及.I confirm that there will be no incompatible work.
3.我因此批准该项上锁挂牌作业.I hereby approve thelockout and tagoutwork.
建造经理/生产经理签字Signed by fabrication/production manager:
□是Yes□不适用N/A集体挂锁对隔离点上锁，将标牌挂在集体锁上。Use the collective padlock and tagout on it.
监护人签名Signed by watchman：；申请人签名Signed by applicant：。
第二步STEP 2：安全监管人员审核REVIEWED BY SAFETY PERSONNEL
□是Yes□不适用N/A拉警戒线限定安全区域Cordon off areas for distance of safe limits.
□是Yes□不适用N/A在所有可能进入受影响区域入口处突出显示警示板Prominent display of warning signboards at all possible access to the affected work area.
领班/第三方承包商主管签字Signed by foreman/ contractor’s supervisor:
第五步STEP 5：申请人完工通告NOTIFICATION OF WORK COMPLETION BY APPLICANT
上述上锁挂牌作业暂停/完成于The abovelockout and tagoutworkisstopped/completed on:年Y月M日D:
□是Yes□不适用N/A确认能量已隔离或去除Confirmed the energies have been isolated or removed.
□是Yes□不适用N/A个人挂锁对隔离点上锁，将标牌挂在个人锁上。Use the individual padlock and tagout on it.
我已检查确认所有安全要求已经遵照执行I have inspectedand confirm that all safety measures have beenimplemented.
安全监管人员签字Signed by safety personnel：
第三步STEP 3：建造经理/生产经理审批APPROVED BY FABRICATION/ PRODUCTION MANAGER
第一步STEP 1：领班/监督申请APPLICATION BY FOREMAN OR SUPERVISOR
我已采取措施使该区域适合上锁挂牌作业申请，在施工前我将确保落实以下措施，在施工过程中做好维持。I have taken measure to render the area safe and fit forlockout and tagoutworkapplication. I shall also ensure compliance with the under-mentioned prior to the commencement and during the work.
上锁挂牌作业许可
PERMIT FORLOCKOUT AND TAGOUT
ZHJT-MR-09/R01
隔离点数量No. of isolation point:；作业人数No. of operator:。
编号Serial No.：LT
项目PROJECT/厂房WORKSHOP:；位置LOCATION:。
作业描述DESCRIPTION OF WORK：。
申请人签字Signed by applicant：；安全监督人员签字Signed by HSE：
第一联original（白white）：现场张贴display on site;第二联duplicate（红red）申请人留存Applicant;
第三联triplicate（黄yellow）批准人留存Approver;第四联quadruplicate（蓝blue）安全人员留存HSE.
第四步STEP 4：领班/第三方承包商主管签收SIGNED BY FOREMAN/ CONTRACTOR’S SUPERVISOR
我将在作业前采取要求的安全措施，在第三步批准后负责整个作业过程的维持I shall take the safety measures as stated in step 1 prior to the commencement of the work process after the step 3 has approved and shall be responsible for maintaining them during the entire work process.
□是Yes□不适用N/A清理受影响区域所有无关人员Cl from the affected work area.
□是Yes□不适用N/A安排专人现场监控Assign responsible personnel to supervise the operation.
1.我确认相关影响区域已执行了彻底的检查及合理评估，所有安全措施已经采取Iconfirm that a thorough inspection and proper assessment ofaffectedarea have been carried out all the necessary safety measure have been taken.
