Use of Nonintrinsically Safe Equipment

To: Operation Installation Manager WOP/1 or EOP/1 or DOP/1 Subject: Permission to bring / use non-intrinsically safe equipment to Offshore East/West
*Mandatory Information

Brunei Shell Petroleum Co Sdn Bhd

Name* Contract holder (nonBSP)* I.C / Service Number* Equipment / Item* Haji Asrul Saniy AEO/4 Make*

Ref. Indicator* Contractor*

SKSWo od

Serial Number*

Propose date Justification(s) Supervisor Name * Signature

From

To

The reason(s) for me to bring / use is (are): Personal Use

Andreas Halim

I, the above named, request permission to bring and use the above non-intrinsically safe equipment(s) to FAIRLEY / AMPA / CHAMPION * in compliance to BSP-02-POLICY-114 (Rev 1.0) & BSP-14-Procedure-1625 (Rev 7.2). I will abide by the requirement that it is only permitted to use the above mentioned item(s) inside the accommodation area. i.e. FAAP04, AMLQ09, CPLQ7 or vessels /drilling rigs name (AEO vessel) living quarters. I understand that any non-compliance will have this permission revoked and Consequence Management applied to me. Sincerely,

.............. (Applicant: ) For West-LT Use Only Name of OIM Ref. Indicator Date Request Permission valid until Approval Division

: : Approve d :

Signatur e : Reject

Use of Nonintrinsically Safe Equipment

Remarks : To Be Used INSIDE the Living Quarter and accommodation Barge/Boat ONLY

Brunei Shell Petroleum Co Sdn Bhd

How to fill in the form or reason why such info is needed

Name: The person who is going to use or bring the equipment and responsible for safe handling / use Indicator: BSP Indicator Contract Holder (None BSP staff): For none BSP, the contract holder will be responsible to the staff under his watch. He may / may not allow the application to proceed. Contractor: Name of the person whom the application working for. This will be easier for us to follow up is needed. Equipment / Items, Make and Serial number: All info needed. This will allow to cross check if the individual is carrying his/her equipment and not the others Personal / Business Use (delete one or keep both) Justification: Reason why the equipment is needed Supervisor name and Signature: Needed to make sure the supervisor is fully aware that the applicant is taking NISE to offshore location where strict rules applied Applicant name and signature: This is to confirm that the applicant is abide to the rules and regulations. Name of OIM: Only those names are allowed to approved. Acting OIM will not be granted to provide approval Date: The date when OIM approved the application Signature: Is the signature of OIM on duty and who give the permission Request: Either approved or reject (one will be cancelled) Permission valid: Its up to OIM to decide based on information received Remarks: Its either left blank or provide additional requirement Note: The form is available in WOP webpage. Once updated, hard copy need to be send to AMPA or FAIRLEY OIM Snr PIP is supporting OIM to administered/compile the form

Use of Nonintrinsically Safe Equipment

Brunei Shell Petroleum Co Sdn Bhd

Applicant be given original copy or scanned copy. Its invidual responsibility to show the approved form to security at KBP or AKI or other port Incomplete form will not be processed