Appendix 1 to Annex B

Annex B Appendix 1 To Loughborough University Estates Services Health and Safety Policy PERMIT TO WORK PRESSURE SYSTEMS (To be made in duplicate; Cancellation of Permit to be retained)

BOILERS, PRESSURE VESSLES, SYSTEMS PART 1 I hereby declare it is safe to work on the following equipment, which has been isolated and prepared in accordance with the Pressure Regulations 2000 and LU Estates Services Safety Regulations and Procedures, Pressure Systems. The person permitted to work is aware of the relevant safety Regulations in this section.

Establishment…………………………………………………………………………………..………………………

Building/Installation…………………………………………………………………………………………………….

Equipment Identification No……………………………………………………..…………………………………… State here the action, which has been taken to isolate and prepare the equipment) …………………………………………………………………………………………………………………………… Danger and Caution Notices have been posted at…………………………………………………………………

Signed…………………………… Officer-in-charge of the Plant Time……………….hrs Date…………………………

PART II I acknowledge holding this Permit and declare that I am in Charge of the work set out thereon. I am aware of the safety arrangements and declare that no attempt will be made by me or by men under my control to work on any other equipment.

Signed …………………………………………………………………….….. Time……………………..hrs

In the employ of……………………………………………………………… Date ………………………..

NOTES: A The Person Issuing this permit is to: (1) Fill in and sign Part I of the Permit and the copy contained in the Book and hand the Permit to the person permitted-to-work. (2) Destroy the Permit when the section contained in the Book covering Return of Permit has been filled in and signed. (3) Sign the section contained in the Book covering Cancellation of Permit to confirm that action as at A (2) has been taken. B The person permitted-to-work is to: (1) Acknowledge holding the Permit by signing Part II of the Permit and of the copy contained in the book. (2) Retain the Permit while the work is proceeding. Return the Permit when the work is completed/suspended, and fill in and sign the section contained in the Book covering Return of Permit.

RETURN OF PERMIT I hereby declare that the work detailed in Part I of the Permit has been completed and that all men under my charge have been warned that it is no longer safe to work on the equipment on the Permit.

Signed ………………………………………….…………………………. Time ………………….hrs

In the employ of ………………………………………………………….. Date ……………………...

CANCELLATION OF PERMIT I hereby declare that the Permit is cancelled and has been destroyed by me.

Signed ………………………… Officer-in-Charge Time ………………hrs Date ……………………… August 2004 1