THIS CHECKLIST IS TO BE COMPLETED PRIOR TO ALL CONFINED SPACE ENTRIES AND RETAINED FOR AT LEAST ONE MONTH . Checklist must be completed by a CSE Competent Person.
Entry/Access Permit Number
Confined Space Location
Description of Works
Enter the names of Entry Personnel and Expiry Date of CSE Ticket
Enter the names of Surface Personnel and Expiry Date of CSE Ticket
Relevant Emergency contact numbers are accessible on site ?
Electrical Isolation Required
Mechanical Isolation Required
Contact with System Operator Required
Required Isolation in Place - Checked by
Oxygen b/w 19.5% to 23.5% : Explosive Gas <5% LEL : Hydrogen Sulphide <10ppm : Carbon Monoxide <30ppm
Record Peak Test Readings Prior To Entry
Explosive Gas (LEL%)
Hydrogen Sulphide (ppm)
Carbon Monoxide (ppm)
Other Gases Tested
Select any of the following that will be taken into consideration before entry into the Confined Space
Trade Waste Discharge
Select relevant PPE to be worn or carried by persons entering the Confined Space.
First Aid Kit
Helmet, Boots, Safety Vest
Overalls, Chemical Suite
2 Way Radio
Self Rescue Respirator
Fall Arrest Device
Has the area been cleared of combustible materials for 15m ?
Have all drains within 15m been covered with a wet fireproof blanket ?
Will hot work be performed in the Confined Space ?
Are appropriate fire extinguishes on site ?
List the type of Extinguishers .
Is a water hose available & tested on site ?
If no, list precautions taken to substitute a water hose.
Is extra ventilation required ?
If "YES" what type and where will it be located.
All power leads clear of pipelines ?
All power leads clear of access way ?
Will the Hot works release toxic vapours ?
If "YES", describe the controls to be implemented to enable Hot Works to be performed safely.
Are welding machines/gas bottles at least 8m from the manhole/pit entry ?
Are electric welders earthed ?
Are welders serviced to manufacturers specifications ?
I have checked the above conditions and consider it safe to carry out this work.
CONTACT CITY WEST WATER FOR ENTRY TIME - 9313 8499
CWW Operator Name
The Confined Space described in this Entry Checklist is in my opinion safe to enter using precautions listed above and all persons are properly trained to perform this work.
All persons have left the Confined Space. No further Entries Permitted without New Permit
CONTACT CITY WEST WATER FOR EXIT TIME - 9313 8499
CWW Operator Name