电气第二种工作票(1)

葫芦岛恒泰热力有限公司

电气第二种工作票

_____________班组编号____________

1.工作负责人(监护人)：___________________

2.工作班组人员（不包括工作负责人）：_______________________________________ 共____人

3.工作任务：________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

4.计划工作时间：

自__________年_______月______日______时______分

至__________年_______月______日______时______分

5.工作条件(停电或不停电)：__________________________________________________________________ ___________________________________________________________________________________________

6.注意事项(安全措施)：____________________________________________________________________

___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________工作票签发人签名________________签发日期_____月____日____时____分

7.补充安全措施：_____________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 8.许可开始工作时间________月_____日______时________分

工作许可人签名________________ 工作负责人签名_______________

9.工作票延期

有效期延长到____月____日______时____分

工作许可人签名_______________________ ________月_____日______时________分

工作负责人签名_______________________ ________月_____日______时________分

10.工作票终结

工作结束时间_______ 月____ 日______时_______分

工作许可人签名_______________________ ________月_____日______时________分

工作负责人签名_______________________ ________月_____日______时________分

11.备注：____________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________