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    Confined Space Permit

    Uploaded by

    nonstopalfred

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Confined Space Permit

    Uploaded by

    nonstopalfred
    15 views3 pages

    Original Title

    CONFINED SPACE PERMIT

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    15 views3 pages

    Confined Space Permit

    Uploaded by

    nonstopalfred

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Company Name

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    DEPARTMENT
    CONFINED SPACE PERMIT
    Document Number: Revision Number: Page: Date:
    00 Page 1 of 2
    This permit must be signed by the authorised Competent Person in direct control of work before any work proceeds.
    Only the listed work may be carried out.

    Site:
    Date: Person in Charge of Work:

    GENERAL
    Location of task: Permit Number:
    Description of task:

    Permit Issuer: Signature, Date and Time:


    Work cannot proceed until a completed JSA and /or a risk assessment is available
    RISK CONTROL MEASURES (All sections must be completed)
    Requirements
    Pre-entry requirements YES NO N/A YES NO N/A
    Lockout - Tagout/de-energize Hot work permit
    Pipes(s) broken or capped or blanked Fall arrest harness/
    Purge, flush or drain Lifeline/Tripod
    Ventilation: Hardhat
    Secure area Gloves
    Safe lighting Safety glasses
    Non-sparking tools Respirator, type
    Communication method: Breathing Apparatus
    Contractor employees involved Other PPE:
    Additional info or equipment required for safety: Emergency Rescue
    Procedures in place and communicated to staff Yes / No
    Space-monitoring results Test 1 Test 2 Test 3 Test 4
    Monitor at least every four hours Permissible entry Time: Time: Time: Time:
    levels Initial: Initial: Initial: Initial:
    Percent oxygen 19.5% to 23.5%
    Combustible gas Less than 10% LEL
    Other toxic gas
    Other toxic gas
    Other gases:

    Yes No
    Possible atmospheric hazards YES NO N/A
    Lack of oxygen
    Combustible gases
    Combustible vapours
    Combustible dusts
    Toxic gases/vapours
    Possible non-atmospheric hazards
    Noise
    Chemical contact
    Electrical hazard
    Mechanical exposure
    Temperature extreme
    Engulfment
    Entrapment
    Other non-atmospheric hazardsCopy of permit must remain at the job site until work is completed Page 1 of 2
    Disclaimer: Hard copies of this document are considered uncontrolled. Please refer to the safety office latest version.
    Other Precautions Required
    Warning notices/barricades
    Smoking forbidden
    All persons have been trained
    Intrinsically safe equipment
    Communication equipment

    Number of Stand-by personnel required:


    Name and Phone number:

    Department and Phone Number:

    Entry Supervisor or Qualified Person Signature:

    AUTHORITY TO ENTER
    The risk control measures and precautions appropriate for the safe entry and execution of the tasks in the
    confined space has been implemented and the persons required to work in the confined/restricted space have been advised of
    and understand the requirements of this written authority.

    Name:

    Signed:………………………………………..
    (Authorised Competent Person in direct control) Date:………………… Time:………...

    This written authority is valid until: Date: ………………… Time: …………….

    PERSONS REQUIRED TO ENTER CONFINED SPACE


    We have been advised of and understand the risk control measures and precautions to be observed for entry, exit and work in
    the confined space.
    ENTRY EXIT
    Name/Signature Date Time Name/Signature Date Time

    CANCELLATION OF PERMIT YES NO


    All persons and equipment, plant and materials accounted for
    Equipment checked and restored correctly
    Work has been completed
    Access to the space has been secured

    Name: Signed:

    Date: Time:
    Copy of permit must remain at the job site until work is completed Page 2 of 2
    Disclaimer: Hard copies of this document are considered uncontrolled. Please refer to the safety office latest version.
    Remarks or comments:

    The completed form must be maintained on file

    Copy of permit must remain at the job site until work is completed Page 3 of 2
    Disclaimer: Hard copies of this document are considered uncontrolled. Please refer to the safety office latest version.

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