Work Permit - Confined Spaces

• Site conducted

  Select
• Location
  Address

Part A - Complete Prior to the Commencement of Work

Preparation

• Plant / Area to be worked on:

• Commencing Time and Date:

  Date

• Completion Time and Date:

  Date

• The above area identified, has been isolated from:

• Ingress of Dangerous Fumes?

  Yes

  No

  N/A

• Sources of Electrical Power:

  Yes

  No

  N/A

• Gas or Liquids under pressure:

  Yes

  No

  N/A

• Steam or Heat:

  Yes

  No

  N/A

• Additional Permits Required:

  Select Hot Works Working at Height Electrical General

  • Hot Works
  • Working at Height
  • Electrical
  • General

Atmospheric Tests

• The atmosphere has been found to be satisfactory for work to be carried out with / without * the use of breathing apparatus:

  Without

  With

Safety Precautions

• In addition to isolation procedures listed above in Part A above, select the safety precautions that have been taken:

  Select Breathing Apparatus Lifebelt And Rope Held On The Outside Of The Confined Space Eye Protection Protective Clothing Dust Respirator Non-Sparking Approved Tools Exhaust Fan Others (please specify)

  • Breathing Apparatus
  • Lifebelt And Rope Held On The Outside Of The Confined Space
  • Eye Protection
  • Protective Clothing
  • Dust Respirator
  • Non-Sparking Approved Tools
  • Exhaust Fan
  • Others (please specify)

• Comment:

Authorisation

• Name of Authorized Ace Express Staff Member:

• Date and Time of Authorization:

  Date

Acceptance of Permit

• I hereby confirm that the necessary safety precautions have been taken and it is now safe to enter the confined space mentioned in this permit

• Name of Contractor Company:

• Signature of Contractor:

  Sign

PART B - POST COMPLETION OF WORK

• The work has / has not * been completed and all personnel under my supervision withdrawn.

  Has

  Has Not

• Comment:

• Name of Contractor and Company:

• Contractor Signature:

  Sign

Cancellation of Permit

• The work has been completed and all personnel, materials and equipment have been withdrawn:

• The work has not been completed but all personnel have been withdrawn:

• This permit is now cancelled. A new permit will be required to allow work to continue:

• Name and Signature of Authorized Ace Express Staff Member:

  Sign