SECTION 1.

GENERAL
Details
Date

Confined Space Registration Number

Equipment Number
SECTION 2. RISK ASSESSMENT AND RISK CONTROL
All responses in Sections A, B, C and D must be Yes or N/A, before authorising this permit.
Isolation
A

Yes

The equipment has been Isolated, Secured and Locked in accordance with the standards outlined in
(Hazardous Energy Control and General Work Permits).
Cleaning and purging

Yes

The Confined Space been adequately purged and cleaned of chemicals, solids, scale and other
residual material to allow safe access.
Atmospheric Testing
Authorised Gas Tester to complete the applicable exposure levels before start of work

Gas Test Results

Gas

Acceptable
Levels

Oxygen (O2)

19.5 23.5 %

Yes

LEL %

< 5 % LEL

Yes

Carbon Monoxide
(CO)

< 30 ppm

Yes

Sulphur Dioxide
(SO2)

Top

Bottom

Other

< 2 ppm

Yes

N/A

< 10 ppm

Yes

N/A

(refer notes below)

Hydrogen Sulphide
(H2S)

Safe Level

(refer notes below)

Nitrogen Dioxide
(NO2)

< 3 ppm
Yes
N/A
(refer note 3 below)
Notes: 1. The atmosphere must be tested for Hydrogen Sulphide (H 2S) and Sulphur Dioxide (SO2) where
Confined Spaces may be affected by SPS or Calciner emissions;
2. The atmosphere must be tested for Hydrogen Sulphide (H 2S) when working in underground pits,
sewers or fuel tanks.
3. The atmosphere must be tested for NO2 if diesel powered internal combustion engines have been
operating within the Confined Space.
Rescue Plan
Yes
D

I will attach a copy of the relevant Confined Space Hazard Assessment and Rescue Plan to the
original copy of this permit.

SECTION 3: CSEP AUTHORISATION (to be completed by CSEP Authorised Person)

I am satisfied that it is safe to enter this Confined Space
Name:

Date of authorisation:

_____ / _____ / 20____

Signature:

Time of authorisation:

____________ am / pm

SECTION 4: CSEP CANCELLATION (to be completed by CSEP Authorised Person)

No Personal Danger Tags remain on the Confined Space Entry Permit Board, all equipment has been removed from
the Confined Space, and all GWPs associated with this CSEP have been cancelled.
Name:

Date of cancellation:

_____ / _____ / 20____

Signature:

Time of cancellation:

____________ am / pm