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THELine Break Permit <br /> NE GROUP <br /> Section 1: Prior to Starting Work Section 2: Pump Down Precautions <br /> �5 Points of caution before to remov <br /> ing <br /> Permit Requested by: re �, ) <br /> (Initial that each concern has been <br /> Date: f(' — Work Order: I 1{ � Isolation valves closed and locked out <br /> / C nn Solenoid valves,regulators,and actuated check <br /> Affected Location Area: >( i_4 valves are manually open <br /> Equipment Being Opened: y �� 4 All line break personnel are wearing required PPE <br /> �y Points of caution during pump down (Initial that each <br /> Company performingline break: concern has-been reviewed and mitigated if present) <br /> N��r <br /> (print)and signature of person performing line break: Ice on or forming on desired lines <br /> �­__ <br /> (� non actuated check valves trapping liquid <br /> N,%print)and signature of line break attendant:: <br /> Defective gauges <br /> Drop VE an ow pornts t at could trap oil or <br /> �i,,q ammonia <br /> Estimated Time Frame Plant authorization <br /> (in days) of timeframe 'I Plugged service/hand valves <br /> Pump down(vacuum)verification: <br /> Pump Down Name: C0111141f Note:Final reading must be at least 30 minutes after initial <br /> ystem pen ( niUa Date/' <br /> .� <br /> Down time Title: 3,�,�,-�:TJr vacuum reading: Time: NiJ <br /> Evacuation/ I Finalr Date <br /> testing/startup Signature: �— vacuum readin Time: <br /> Total Time ( Date: ol'lo Section I Line Break Approval <br /> Extension request(If required) Section 3 must be signed by a trained and authorized line <br /> rtrona break supervisor prior to irreversible entry. <br /> Time required Signature: Date: S Time: .7v <br /> =.. <br /> Valve5-to be Locked out(Tag ID's): Li "Break Approval <br /> Confirmed Isolation and LOTO(supervisor initials) <br /> System will be evacuated with:(Circle) JiV Verification of Vacuum(supervisor initials) <br /> Water Su fi Other: Name('print)and signature of line break supervisor: <br /> !� (, <br /> System will be tested with: (Circle) <br /> Nitrogen Air System ystem Liquid <br /> Gas Pressure Pres su lection 4: Line Break Completion <br /> Checklist(Initial each box to confirm) Prior to reintroducing ammonia,verify vacuum and sign <br /> ( <br /> personnel aware of evacuation pr ures, eye <br /> wash locations,and line break procedure(SOP) Vacuum Reading Date: <br /> require ine rea equipment,sa ety equipment, <br /> W4 and lock out equipment are at line break location a(pit)an'' mature per�on�p�rmi line break: <br /> Reviewedassignedroles or eac person involved In - i <br /> line break Name( in arra ' n tire of line <br /> Notified a personnelin area that line breakis a i�ut �ak supervisor: <br /> to be conducted �. <br /> In case of emergency call <br /> Fire/Police/Ambulance Dial 911 Name: Number: <br />