CONFINED SPACE ENTRY PERMIT

Permit Number:
A – DESCRIPTION OF THE WORK TO CARRY OUT
Work Location / Area Description of the Work Yes No Comments
Flame Cutting ☐ ☐
Grinding ☐ ☐
Arc Welding ☐ ☐
Blast cleaning Abrasives ☐ ☐
Epoxy painting spray ☐ ☐
Cleaning of the structure with water ☐ ☐
Mechanical work ☐ ☐
List of tools and equipment to be used

Date: Time of Entrance: Time of Exit: (Permit valid 12h maxi)

Name of the Foreman: Name of the Supervisor:

B – MANDATORY PREPARATION
Items Yes No N/A Items Yes No N/A
1. Test of presence of gas/oxygen
☐ ☐ ☐ 2. Electrical authorization needed ☐ ☐ ☐
mandatory
3. Anti-explosion and low voltage lights
(under 12V or 120V with avec circuit ☐ ☐ ☐ 4. Use of scaffolding ☐ ☐ ☐
breaker)
5. Appropriate Ventilation ☐ ☐ ☐ 6. Identify the safety area at the entry ☐ ☐ ☐
7. Inspection of the equipment before 8. Safety signage or warning required
☐ ☐ ☐ ☐ ☐ ☐
use (ex : smoking ban)
10. Additional staff required for work or
9. Communication Equipment ☐ ☐ ☐ ☐ ☐ ☐
supervision
12. Safety initial induction session required
11. Fire fighting equipment mandatory ☐ ☐ ☐ ☐ ☐ ☐
before works start
13. Removal or protection of potential
☐ ☐ ☐ 14. Other: ☐ ☐ ☐
flammable and dangerous materials

C – PERSONAL PROTECTION EQUIPMENT (PPE)

☐ Cotton clothes ☐ Gloves: ☐ Respiratory protection
☐ ADF or PVC special clothes ☐ handling gloves ☐ ARI
☐ Safety shoes ☐ chemical gloves ☐ Filter cartridge mask
☐ Safety helmet ☐ anti-heat gloves ☐ Eye protection:
☐ Harness and lifeline ☐ isolating gloves ☐ Waterproof protection
☐ Hearing protection ☐ Leather apron ☐ Face shield
☐ Waterproof boots ☐ Hood (sanding / welding) ☐ Others

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 CONFINED SPACE ENTRY PERMIT

D – FOLLOW-UP OF THE CONDITIONS – Results to be recorded every _______ hours

Oxygen (O 2 %) Explosiveness (% LIE) H2S CO
Time Signature
Min:19,5% / Max: 23% Max: 10% Max: 10 ppm Max: 35 ppm

Name of the person entering Signature Entry time Exit time

E – VALIDATION AND APPROVAL F – CLOSURE

We certify that we have checked the equipment and working methods applicable and confirm that the We confirm that we have inspected the site where the operations in this permit took place and confirm
operations must be carried out under the safety conditions as defined above. that it presents no danger for people or the Environment.
Contractor Permit Issuer Q-HSE dpt. Permit issuer Inspector (HOD / Q-HSE Coord.)

Name/Date/signature Name/Date/signature Name/Date/signature Name/Date/signature Name/Date/signature

EMERGENCY CONTACT:

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This document is the property of UNI Engineers Uganda Ltd; Distribution and reproduction prohibited without authorization of the Q-HSE
Manager