Doc.

ID: PP710-CSE-F04
Confined Space Entry Procedure Issue Date:

Attachment No. 4 Rev. No. A Rev. Date: 2-Jan-14

Data Update:
Confined Space Entry Form Page No.
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CONFINED SPACE ENTRY PERMIT: NO:

DESCRIPTION OF THE TIME

CONFINED SPACE e.g VESSEL/ PIPE NO. LOCATION DATE FROM TO

SUPERVISOR: WORKERS NAME

Full Description of Work:

SPECIFIC HAZARDOUS TASKS

WELDING/GRINDING/CUTTING PAINTING OR CLEANING WITH SOLVENTS CHEMICAL

ELECTRICAL SCRAPING / REMOVING RESIDUE MAINTENANCE

CLEANING/SWEEPING/VACCUMING ERECT SCAFFOLDING INSPECTION

OTHER EXPLAIN

CHECKLIST FOR ISOLATION AND UNAUTHORIZED ACCESS PREVENTION

YES NO N/A INITIAL

EXTERNAL BARRIER(S) IN PLACE

MECHANICAL LOCKOUT/TAG OUT

ELECTRICAL LOCKOUT/TAG OUT

LINES/PIPES DISCONNECTED

LINES/PIPES BLINDED/SPADED

WARNING SIGNS

TRAINING INSTRUCTION GIVEN

INITIAL ATMOSPHERIC TESTS PERFORMED

STANDBY MAN REQUIRED

LIFELINES AVAILABLE

OTHERS

CAUTION: Toxic of flammable gases or vapours may stratify in the confined space. Be sure to test at various levels and locations within the confined space.
Always check the oxygen content first.
INITIAL TESTING

TESTER ACCPTABLE
HAZARD TESTED ACCEPTABLE RANGE READING DATE & TIME INITIALS YES NO
% OXYGEN ABOVE 20% %
% LEL FLAMMABLE GAS N.A N.A
H.S P.E.L = N.A PPM = N.A

Issues Signature: Capacity: Date:

Receiver's Signature: Capacity: Date:

MUST Return to Issuer When Work Completed.

Closed out by Issuer: Time: Date:

Closed out by Receiver: Time: Date:

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