CONSIGMENT/DECONSIGMENT CERTIFICATE (LOTO PROCUDURE)
REV: C
Company………… SL No……… Date………
Person in charge Mr./MS……………………………………………………………….for Execution of the following work
…………………………………………………………………………………………………….on the equipment’s mentioned here
………………………………………………………………………………………………………………………………………………………………………
Mr……………………….In-charge of this task ……………………………………………………………………………
Telephone number…………………………………Attest that for the work , he made consignment of……………………..
………………………………………………………………………………………………………………………………………………………………………
………………………………….
Super-in charge shall consider all other electrical equipment’s besides which is mentioned in this
consignment or for other consignments certificate which he /she has Request should consider as
charged.so high CAUTION IS REQURIED.
AT what Hours the Feeder was lock / released Mention here…………………..
Permit Issuer FFM (sign) OCP Forman (sign) permit Receiver (sign)
Task Complete (LOTO PROCUDURE) C
Manager In-Charge Mr. /Ms.………………………………………………………………..
Company……………………………….Likewise Mr.…………………………………….In-Charge of the consignment , that
mentioned in this Task is completed at Date……………..Hours……………..Minutes and his workers have been
informed. Supervisor in charge declare that he had removed all the safety Disposition and put all the
equipment’s in Ready to Start Mode without the power supply.
Mr. /Ms.…………………………………………Supervisor in charge shall make sure that His or Her Manpower ,Tool &
Tackle have been removed for that Area.
Permit Issuer (Sign) OCP Forman (Sign) Permit Receiver (sign)
