Information
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Document No.
Information
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This permit is valid only for the date and time specified.
The Site Manager/supervisor (Permit Issuer) is responsible for ensuring the permit has been satisfactorily completed, prior to the commencement of work.
When the work is complete or this permit expires, the authorised person for the confined space work must sign off the permit.
Work Details (Completed by Employees in charge of work)
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Confined Space Permit No: (e.g. CSWP 0001)
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Date of Issue:
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Time:
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Name of person issuing permit:
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Proposed work to be carried out and location:
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Confined Space Details (Gas Monitor Levels, Confined Space No.):
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Confined Space No.
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Oxygen %
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Comb/Ex %LEL
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CO (Ppm)
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H2S (Ppm)
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Confined Space No.
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Oxygen %
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Comb/Ex %LEL
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CO (Ppm)
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H2S (Ppm)
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Confined Space No.
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Oxygen %
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Comb/Ex %LEL
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CO (Ppm)
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H2S (Ppm)
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Confined Space No.
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Oxygen %
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Comb/Ex %LEL
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CO (Ppm)
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H2S (Ppm)
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Confined Space No.
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Oxygen %
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Comb/Ex %LEL
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CO (Ppm)
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H2S (Ppm)
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Confined Space No.
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Oxygen %
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Comb/Ex %LEL
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CO (Ppm)
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H2S (Ppm)
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Confined Space No.
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Oxygen %
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Comb/Ex %LEL
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CO (Ppm)
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H2S (Ppm)
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Confined Space No.
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Oxygen %
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Comb/Ex %LEL
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CO (Ppm)
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H2S (Ppm)
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Confined Space No.
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Oxygen %
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Comb/Ex %LEL
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CO (Ppm)
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H2S (Ppm)
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Name of person entering confined space:
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Name of stand-by person:
Permit Requirements (Completed by Employees in charge of work)
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1 - Are any mechanical, electrical, pipe, valve or other isolations required?<br>Specify. <br>For example, pipelines (water, steam or gas), mechanical or electrical drives. <br>
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2 - Is ventilation equipment required?<br>Specify. Type used.<br>
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3 - All persons, including the stand-by person, have attended an accredited course in Confined Space entry.
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4 - Is safety equipment or personal protective equipment required? <br>Specify PPE to be worn.<br>
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5 - Are danger tags or signs displayed?
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6 - Are there appropriate emergency procedures or equipment in place and understood by all parties entering the work space and stand-by personnel?<br>Specify.<br>
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7 - The conditions for entry are as marked below:<br>a) with supplied air breathing apparatus<br>b) without respiratory protection with escape unit.<br>
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8 - Calibration Bump Test completed?
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9 - Have the levels of ventilation and oxygen/contaminants been checked?<br>Atmospheric Issue Safe Level<br>Oxygen > 19.5 % and up to 23.5%<br>Comb/Ex < 5% of its LEL<br>CO < 30 ppm<br>H2S < 10 ppm<br>Please record gas readings for each location:<br>
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10 - Are toxic gases, solids or liquids present?
Authorisation (Completed by Permit Issuer)
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Permit Validity: The duration of the confined space work permit must not exceed more than one (1) day, after which a new permit must be issued
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From Date and To Date:
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From Time and To Time:
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Name of Permit Issuer:
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Signature of Permit Issuer:
Log in/out (Completed by stand-by persons performing confined space work)
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Log In
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Log Out
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Log In
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Log Out
Close out (Name of person performing confined space work)
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Name:
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Date:
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Time:
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Completion (Completed by Permit Issuer)
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Permit returned to HSE Manager, work completed.
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Name:
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Date:
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