Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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The Person Responsible For Direct control of The Confined Space Work Site
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NAME
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Work to be carried out:
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This Entry Permit is Valid From
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Select date
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To
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Select date
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Precaution: (tick if Required)
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Precaution: (tick if Required)
- NO HOT WORK
- Warning signs
- Barricades
- No Smoking
- Emergencey Procedures in place
- Communication Established
- HOT WORK REQUIRED
- Remove Combustible materials
- suitable Fire Extinguisher
- Fire hose- Running water
- Confined Space must be continuously forced ventilated by suitable blower fan
- Other
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HAZARDS ISOLATED & PPE
- Electrical
- Mechanical
- Chemical
- Water Mains
- Sewer Mains
- pump station rising Mains
- Stormwater
- Other
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Continuous Monitoring Required
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Date gas monitor Last Tested
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SAFETY EQUIPMENT
- Gas Monitor
- Safety Harness
- Safety line/ R.P.G
- Tripod, Davit Arm, Manhole. Frame
- Ventilation fan blower
- Pipe Plugs
- Hard Hat
- Safety Boot
- protective gloves
- Safety glasses
- Hear protection
- Gloves
- Other
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S.C.G.A if ticketed complete
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Air pressure S.C.B.A cylinder in bars
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Air pressure S.C.B.A cylinder in bars
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Date BA. Was last tested
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By whom
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Faults and/ or Incidents Observed. NOTE: Inform SUPERVISOR & fill accident/ indent report forms as required
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COMPETENT STANDBY PERSON
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NAME
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NAME
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NAME
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COMPENETENT PERSON ENTERING CONFINED SPACE
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NAME
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TIME IN:
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TIME OUT:
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NAME
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TIME IN:
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TIME OUT:
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NAME
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TIME IN:
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TIME OUT:
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NAME
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TIME IN:
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TIME OUT:
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NAME
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TIME IN:
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TIME OUT:
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SAFE TO ENTER SIGNED BY THE RESPONSIBLE PERSON
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The Work Team & Contractor are trained, equipped & understand procedure for this entry
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this area is safe to enter according to the above conditions
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SIGNING OUT SIGNED BY THE RESPONSIBLE PERSON
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All Work in or on the confined space has CEASED
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ALL PERSONNEL HAVE LEFT THE CONFINED SPACE
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All Isolation & TAG OUT Removed
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JOB CLOSED AT TIME
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