Return to Service Permit / Section D / Chapter 5
Part C
Version: 0
Re-Energize Return to Service Permit
Location/Facility: Date/Time:
Re-Energize Procedure(s) to be Performed: Energy Isolation (LO/TO) Process Equipment/Piping Isolation
List Specific Equipment to be Re-Energized:
Check all energy to be Re-Energized: Electrical Mechanical Pressure Hydraulic Gravity
Pneumatic Chemical Thermal Radiation Other:
The person supervising or authorized person shall verify the following by placing a check or “X” in the box signifying each item has been considered and/or completed:
Verify the following when Re-Energizing and Returning Equipment to Service:
Check / Description / Initials1. JSA (Job Safety Analysis) completed and reviewed.
2. If shift change, have daily logs or notes been reviewed.
3. Site, location, area, equipment to be re-energized has been visually inspected.
4. All affected personnel have been notified.
5. All non-essential items have been removed from machine or equipment.
6. Machine, equipment and/or piping components are operationally intact.
7. All employees are safely positioned or removed from the area.
8. Controls, switches, valves, knobs, etc. are in the correct start-up or normal operating position.
9. Locks, tags, chains, blind flanges or devices have been removed according to the LOTO Log.
10. Re-energize equipment or components, test and/or verified equipment is safe to operate.
11. Notify all affected employees that equipment is ready for use or return service.
12. Update energy isolation status in the facility LOTO log book.
The undersigned have reviewed the above information and will comply with the conditions set forth by this permit. They understand that the permit is void if these conditions change.
Signatures:
Immediate Supervisor of Job/Task: Name (Print): Company:
Signature: Date:
Facility Person in Charge (PIC) or Consultant (Print): Company:
Signature: Date:
Safe Work Practices June 2017