CONCORDE- CORODEX GROUP

CONFINED SPACE ENTRY PERMIT

Division: Location of Space:

Project Name: Type of Space

(Tank, pipeline, manhole, etc.):

Reason for Entry:

Atmospheric Hazards:
 Oxygen Deficiency  Combustible Gas  Toxic contaminants  Others _______________

Physical Hazards:  N/A  Mechanical  Electrical  Heat

Hazard Controls:  N/A  Ventilation  Lock Out/ Tag Out
Beginning Date: Time: Ending Date: Time:
AUTHORIZED PERSONNEL
Entrants’ Names Company Attendant’s Name Company

REQUIREMENT EQUIPMENT
Communication Method with Entrants:
 Voice  Radio  Phone  Visual  Others __________________________

Communication methods to contact Emergency Services:

 Radio  Phone  Others _________________________

PPE:
 Coveralls  Hand protection (Specify) ________________  Eye protection (Specify) ______________
 Safety Shoes  Head Protection (Specify) ___________  Hearing Aid  Respiratory protection
 Hardness / Life Line  Others (Specify): ____________________________________________
Traffic Control: Hot works:  N/A  No
 N/A  Barricades  Vests  Flags  Signs  Yes (attach the Hot work permit)
Atmospheric Testing:  N/A  No  Yes

Type of Gas Tests Results

1st 2nd 3rd 4th 5th 6th 7th

Tested by:
APPROVALS

Permit Issuer Permit Receiver

Name: Date: Name: Date:

Rev. 0
ISSUE: A Reference SOP
Dated: --/--/11 CONFINED SPACE ENTRY PERMIT
 CONCORDE- CORODEX GROUP

CONFINED SPACE ENTRY PERMIT

CLOSE OUT (Date work is completed): By:

Rev. 0
ISSUE: A Reference SOP
Dated: --/--/11 CONFINED SPACE ENTRY PERMIT