CONFINED SPACE ENTRY WORK PERMIT
WORK PERMIT No.
Department Section Equipment Tag Nos.
A. Validity of Permit (Date & Time) From To Work Location
B. Job Description: Equipment to be worked on:
Tick in the Appropriate Box
C. Worksite / Equipment Preparation Yes No N/A D. Required PPE Yes No N/A
1. Has been Positively isolated by
Blinds / Disconnected □ Safety Helmets □ Safety Shoe □ Safety Goggles □ Face Shield
2. Has System depressurized / drained / Ventilated
3. Has been water Flushed
□ Ear Plug □ Ear Muff □ Gloves (Cotton/Leather/Chemical/Rubber)
4. Temperature inside OK
5. Has been Purged with Inert Gas
□ Safety Harness □ □ □ □
Safety Net Cover all Fall Arrest Dust Mask
6. Excavation Works
7. Gas Testing (every 4 hours)
□ Half Mask □ □ □ □
Gas Monitor SCBA Air Line Rescue Rope
8. Continuous Gas Testing
9. Artificial Lighting
□ Fire Extinguisher□ □ □
Fire Blancket Edge Protection (Hand Rail) Step Ladder □ Mobile Scaffolding □
10. Electrical Isolation Done
11. If Prime Mover (Motor / Any Moving Parts)
Fixed Scaffolding □ □ □
Manlift □ Boom Loader Barrications & Signages Chemical Suit
disconnection necessary
- If Yes, has been isolated electrically, Tag Provided.
□ Protection against Overhead Live Cables (Double-Insulation)
12. Radiation Isolation Tag No.
Name of stand by person …………………………….
□ Others_________________________________________________________________________
Signature: ……………………………………………………. ________________________________________________________________________________
13. Any Other Information,
E. Gas Test
Date & Time ………………………………. Details & Precautions Accepted Level
Gas Result
Oxygen % 19.5 - 22.5
Combustible LEL % 0
Toxic Gas H2S ppm 5
Toxic Gas - CO ppm 25
Name of Gas Tester: ………………………………………………………………………………………… Signature of Gas Tester: …………………………………………………………………………………………
F. If the Job is carried out by Contractor, Name of Contracting Company …………………………………………………. Contact Person: …………………………………………………………..
G. Permission granted for work to commence H. I understand the Job explanation, preparation, precautions to be taken while
Permit Issuer (Process Owner): executing will inform the issuing authority about any discrepancies.
Name: ……………………………………………………………………………………... Permit requestor: ………………………………………….. Permit Receiver: ………………………………………….
Signature: ………………………………………………………………………………… Signature: ………………………………………………......... Signature: ...................................................
I. Extension of Validity
Date Valid up to
Permit Issuer (Process Owner): Requestor Permit Receiver
J. Completion of work K. Site / Equipment Acceptance
Work completed, housekeeping done & checked. Work checked and site / equipment taken over back after maintenance.
Date & Time:…………………………………………… Electrical Isolation / Tag shall be removed.
Permit Receiver: ………………………….. Permit Requestor: …………………………………. Permit Issuer (Process Owner): ………………………….....…………………………………..........
Signature: …………………………………….. Signature: ………………………………………………. Date & Time: ……………………………………......... Signature: ……………………………….........
White Copy: PTW Book (Issuer), Yellow Copy: Receiver, Blue Copy: Permit Requestor
Safety Dept. Contact No.: 056 417 6699 / 02305 2521 First Aider No. 054 785 5786/ 02305 2536
Document Control No.:
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