Confine Spaces Work Permit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Select date

  Date

• Persons entering confined space

  Select Dean Aitken Ben Earnshaw Keith Falkenburg Ben Buckley Greg Warner Glen Simpson Justin Wood Keith Burt Adrian Kiwara Simon Jowett Other - List Below

  • Dean Aitken
  • Ben Earnshaw
  • Keith Falkenburg
  • Ben Buckley
  • Greg Warner
  • Glen Simpson
  • Justin Wood
  • Keith Burt
  • Adrian Kiwara
  • Simon Jowett
  • Other - List Below

• Name of Company

• Name of Persons

• Confined space training current

  Yes

  No

• Photo of training card

  Media

• Calibration date for gas meter

  Date

• Location of confined space

• Photo of job site

  Media

• Hazards of confined space to be entered

  Select Combustible gases/vapours Electrical Mechanical Chemical Temperature Engulfment Entrapment Flooding None Present

  • Combustible gases/vapours
  • Electrical
  • Mechanical
  • Chemical
  • Temperature
  • Engulfment
  • Entrapment
  • Flooding
  • None Present

• Control measures for any identified hazards

• Gas meter levels outside of confined space O2 - 19.5 - 23.5%, LEL - 0, H2s - 0, CO2 - 25ppm

• Gas meter levels inside of confined space O2 - 19.5 - 23.5%, LEL - 0, H2s - 0, CO2 - 25ppm

Entry Requirements

• PPE required by all persons in the confined space

• Internal to External communications required

  Yes

  No

• Ventilation equipment to be used

  Yes

  No

• Lighting inside confined space sufficient

  Yes

  No

• Hole watch required

  Yes

  No

• Name of hole watch

Sign off

• Pre-entry briefing held

  Yes

  No

• Briefing Details

• Entry authorised by

• Add signature

  Sign

• Permit Expiry

  Date