Confined Space Entry Permit

Relevant information must be filled in and signed by competent person prior to all confined space entries.Completed document to be forwarded to the appropriate Area Manager or Coordinator and must be kept for at least one month.This form applies to all contractors working for LCC.Contractors will remain responsible for their own records.

EMERGENCY CONTACTS

Fire,Ambulance: 000 Remount Road Admin: 6323 3500
Customer Service: 6323 3333 Duty Supervisor (AH): 0437 523 350

GENERAL
Date and Time of Entry

Description Of Confined Space

Location

Description Of Work

Site Photo
HAZARD IDENTIFICATION AND RISK ASSESSMENT

Standard Trench

Gross Polutant Trap

Pump Station

Standard Manhole / Gully Pit

Reservoir

Pipe Walk

Wastewater Treatment Plant

Other

FOR HIGH RISK SITES ATTACH COPY OF WORK INSTRUCTIONS THAT NEED TO BE FOLLOWED

Risk Assessment completed and attached

CONTROL MEASURES ISOLATION (Isolation and Lockout to be undertaken in accordance with procedure 21-HLPr-020)

Warning Notices/Barricades?

Electrical Isolation

Mechanical Isolation

Contact with System Operator

Isolation and Lockout complete

4. ATMOSPHERIC TESTING (Prior to entry)

Gas Detector Serial Number

Oxygen (%)

Explosive Gas (LEL%)

Hydrogen Sulphide (ppm)

Carbon Monoxide (ppm)

Number of atmospheric tests conducted before entering

If two tests have failed, has Manager been notified?
Gas Testing completed by:
5. VENTILATION

Natural

Positive Mechanical (Blow In)

Negative Mechanical (Draw Out)

6. REVIEW CONDITIONS THAT MAY CHANGE STATUS OF CONFINED SPACE

Select any of the following that will be taken into consideration before entry into the Confined Space

Weather

Traffic

Noise

Catchment

Flow Volume

7. PERSONAL PROTECTION EQUIPMENT

Helmet

Waders

Eye Protection

Hearing Protection

Harness

Gloves

Self Rescue Respirator

Lifeline

Fall Arrest device

Gas Detection Meter

2 Way Radio

Other

OTHER PRECAUTIONS

Warning Notices/Barricades?

Hot Work Permit Required? (If yes use Form 21-Fm-012 and attach)

Media

Emergency response Equipment Available on Site:

AUTHORITY TO ENTER

The control measures and precautions appropriate for the safe entry and execution of the work in the confined space have been implemented and the persons required to work in the confined space have been advised of and understand the requirements of this written authority.

Name and Signature
Select date
Entry Permitted
Entry Not Permitted

Induction Of Visitors Done

PERSONS REQUIRED TO ENTER CONFINED SPACE

Number of Standby Personnel (Minimum of one, but when there are three or more persons within the confined space a minimum of two standby persons will be required) Task - E Entry; S Standby; V Visitor.

Competent for Entry

Add signature
Add signature
Add signature

Standby Persons

Add signature
Add signature
Add signature

Visitor

Add signature
Add signature
Add signature
IN CASE OF EMERGENCY EVACUATION

Record Peak Gas Detector Readings and any other relevant information:

Oxygen:

Explosive Gases % LEL:

Hydrogen Sulphide ppm:

Carbon Monoxide ppm:

Gas Detector Serial Number:

Comments......

11. JOB COMPLETION

All persons have left the Confined Space. No Further Entries Permitted Without New Permit

Name and Signature
Select date