Work Permit Permit No:

PLTD-HSE-TEMP-005

Work Activity:
Confined Space Entry Permit Form
A. Application (By Contractors/subcontractors Nominated Person)
Requesting Company: Request By: Date:

Plant Area: Description of Work: (attach drawing/sketch as necessary)

Time Date Time Date

To

Permit is required from

(maximum 1 day)

B. Precautions to be taken prior to commencement and during the work (by Nominated or Competent Person)

Fill by Safety Inspector Yes No Fill by Supervisor Yes No

1. Does explosive gas, hazardous gas and
O2 gas have been tested
2. Does respirator equipment and Line
Life apply
3. Does electric equipment suitable with
requirement
4. Does more ventilation need
5. Does safety man has been appointed
6. Does hazardous material has rip off
7. Does facility such as: ladder, heavy
equipment and so on are apply
8. Other:
1. Does all valve and pipe that connect to
confined space have been closed.
2. Does all valve and pipe has been install
with lock out and tag out
3. Does this system has been free from
pressure and high temperature
4. Does this system has been purging and
flushing
5. Does all blind has been install and give
sign
6. Does DCS has been call
7. Does the supervisor has been
understand with the safe operation
procedure
8. Other:

Special action shall be conducted:

Special advice:

GAS TEST RECORDED

1
PLTD -HSE-TEMP-004
 Work Permit Permit No:
PLTD-HSE-TEMP-005

Gas Explosive : % (Maximum 0 %) Result: Save/ Not save

CO2 : ppm (Maximum 5000 ppm) Result: Save / Not save
Carbon Monoxyde : ppm (Maximum 50 ppm) Result: Save / Not save
Oxygen : % (19.5 % – 21.5 %) Result: Save / Not save
Date Of Calibration : ID Reference of Multi Gas Detector:

A risk assessment and/or a method statement shall be attached to the Permit to Work request.
Yes No Other Control Measures
Oxygen level test result:
No naked light
Total Disconnection
Ventilation fan
Lighting
Observer / Standby Person outside space
Operators to work in Pairs
Constant Oxygen monitoring in place
Monitoring and records sheet
Operators trained in hazards and precautions
Total disconnection from any systems
C. Validated by HSE
Permission is given for the work to proceed subject to the conditions specified above:
Signed Name: Date: Time: Company:

D. Acceptance (to be completed by Subcontractor’s Nominated person)

I certify that have read and understood this permit and that the work will be earned out In accordance with its requirements.
Signed Name: Date: Time: Company:

E. Approved by Authorized Person

Signed Name: Date: Time: Company:

F. Completion of Work (Nominated Person)

I hereby declare that all work for which this permit was issued has been completed, all personnel under my control
have been withdrawn and the work area and any associated equipment have been left in a safe condition.
Signed Name: Date: Time: Company:

G. Cancellation I Completion (Site Manager)

Signed Name: Date: Time: Company:

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PLTD -HSE-TEMP-004