Information
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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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Add signature
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Is the confined spaces permit available and completed
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Are the necessary equipments available
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Gas detector
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Tripod
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Safety harness
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Portable rails
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Fan
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Has the risk assessment been completed and the observations recorded , before the procedure starts?
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Has the technician measured the 4-gas inside the confined space before entering the confined space
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Is the helper / second employee available ( Xylem employee) , with all necessary communication means
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Have been all energy sources locked ( LOTO procedure)
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Has been the Fall protection used and properly installed (harness tripod , portable rails , etc)
