Doc No: BK9A-GEN-000-HSE-CRT-0001 Rev: A

CONFINED SPACE ENTRY CERTIFICATE

CERTIFICATE No.
VALID FOR THE DURATION OF THE PRIMARY WORK PERMIT ONLY
Location of Work: Reason for Entry / Work Description:

Unit / Tag No:

PERFORMING AUTHORITY AGREED FOR WORK TO PROCEED

I, declare that the above confined space is isolated and that the Authorized Gas Tester can, in accordance with company procedure, enter the space to carry
out tests and inspections for the raising of this Entry Certificate.
ANY SPECIAL CONDITIONS ______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________

Signed _______________________ Designation _________ Date ________ Time _____________ Hrs _________

AREA AUTHORITY DECLARATION: I/my appointed delegate authorize that the above confined space can be entered, provided company procedure for
confined space entry is followed

Signed _______________________ Designation _______________________________ Date _______________ Time _____________ Hrs _________

TEST RESULTS Retest every ____________________ Hrs(Maximum 12 hours)

ppm Toxic Specify
Date Time O2 % LEL ______________ Radioactivity Signature

C
S
E
N
o

I, Authorize Gas Tester, declare that the above confined space is safe for Restricted Entry under a Permit to Work

BREATHING APPARATUS NOT REQUIRED

C BREATHING APPARATUS REQUIRED
O I_____________________________________________________________________________________________________________
would make the following observations: ___________________________________________________________________________
N _____________________________________________________________________________________________________________
F Signed __________________ Authorize Gas tester _______________________ Date _______________ Time _____________Hrs ____
I
N
E Performing Authority authorize cancellation of CSE certificate
D Registry of Entry Certificate Cancellation
S (a) All copies of Entry Certificates returned to CoW department
P (b) Notation of Entry Certificates Cancellation made in Permit Register.
A Signed ______________________________________ Date __________________________ Time _______________________ Hrs ___________
C
E
E THIS IS NOT A PERMIT TO WORK
N PERMITTED LIMITS OR CONFINED SPACE ENTRY & WORK
T
R CRITERIA ENTRY WITHOUT BA ENTRY WITH BA
Y (See Section 3) (See Section 6)
C OXYGEN CONTENT (%) 20.8 - 22.5% 19 - 20.8%
E TOXICITY < LTMEL (8 hrs)
(Long Term Exposure Limit)
< STMEL (15 mins)
(Occupational Exposure Limits) (Short Term Exposure Limit)
R (Note 1)
T
I HYDROCARBON VAPOUR < 1% LEL < 4 - 25% LEL
F (% Lower Explosive Limit) (Inspection, Hot or Cold Work permitted) (inspection and Cold Work
I (measured
(Note 2)
on a Combustible Gas Indicator) 1 - 4% LEL
(Inspection and Cold Work Permitted)
permitted)

C (Note 3)
A (Note 3)
T
E Notes 1. If longer work shifts i.e. 12 hours. LTMEL must be extrapolated to give 12 hour
Time Weighted Average (TWA)
2. Lower Explosive Limit (LEL) synonymous with Lower Flammable Limit (LFL)
3. Continuous gas monitoring must be performed throughout confined space occupancy.

Original : Performing Authority: Copy1: Permit to Work Station: Copy 2: CoW Office: