GAS TEST (Only to Be Completed by an AGT)

Corresponding permit to work No. A HOT WORK CERTIFICATE (Only to be completed by authorised persons) Specify location Specify likely ignition sources

OPERATIONAL INFORMATION I have checked, the workplace and reviewed the hazardous areas, and; Yes No  It is free of flammable materials  Sewer and drain systems, and other low lying areas are protected against sparks  The working area is defined with barriers/ signs  Additional fire fighting materials are present and ready for use  A continuous gas detector is installed  A safety guard is continuously present

GAS TEST (Only to be completed by an AGT) Test frequency: Tick if applicable Once before commencement of the work (minute/hourly repeat Test while work is in progress, at specified frequency frequency)

The following working area has been tested for flammable gases/vapours:

Gas test acceptable results:

Acceptable results have to be agreed with the AGT and LPI:

Substance Hydrocarbon Oxygen Other, specify Maximum % of the LEL % Vol ppm Minimum N/A %Vol N/A

Gas tests performed I confirm that I have tested for gas and/or oxygen and that the results are within the specified acceptance levels, and that the measured concentration of explosive gasses/vapours is below the 0% LEL Date Time AGT Signature

Validity of the Hot Work Permit

PI: Permit Holder Hot work as described in the Permit to Work is allowed I certify that I am aware of the between: planned work and the precautions From: detailed on the Permit documents and will ensure that work only Until: proceeds when the conditions set Name: out in the documentation are met.

Signature PI: Signature:

Date / Time: Date:

Form A – Hot Work Certificate Permit to Work System Page 1 of 1