SECTION HSSE

STATUS CONTROLLED
CONFINED SPACE ENTRY PERMIT REFERENCE PPC/HSSE Permit 004

‫شركة التغليف الرئيسة‬ REVISION 0 DATE 11/04/2019

Premier Plastic Company SHEET 1

BUSINESS UNIT :
DATE
PERMIT FOR (Company) : PERMIT NO. :
APPLIED :

SECTION I (ENTRY INFO):

Location of work/Name of confined space : _____________________________________________________________________________________________

Description of work: _______________________________________________________________________________________________________________

Approx. duration of work: From(time) ____________ am/pm To(time) ______________ am/pm

Name of task in-charge: ____________________________________________ Phone No. : _____________________________

Required documents: Method statement: Risk Assessment:

SECTION II (Precautions to avoid potential hazard):

1. Emergency procedures explained to people involved? Yes / No / NR

2. HSSE office informed? Yes / No / NR
3. Communication equipment and distress alarm tested? Yes / No / NR
4. Rescue equipment arranged and at standby locations? Yes / No / NR
5. Confined space purged, ventilated and cooled as necessary? Yes / No / NR
6. Adequate supply of respirable air and effective forced ventilation has been provided? Yes / No / NR
7. Mechanical equipment liable to cause danger effectively shut down? Yes / No / NR
8. Pipelines/tanks/electrical connections liable to create hazards effectively isolated? Yes / No / NR
9. Effective steps taken to prevent ingress of hazardous gas, vapour, dust, or Fume? Yes / No / NR
10. Effective steps taken to prevent in-rush of free flowing solid or liquid? Yes / No / NR
11. Breathing Apparatus provided and will be worn by trained workers in confined space? Yes / No / NR
12 Continuous air monitoring arranged? Yes / No / NR
13 Is an additional permit for Hot/Cold work required? Yes / No / NR
14 Is protective clothing required (specify type)? Yes / No / NR
15 Is full body harness available? Yes / No / NR
16 Is an emergency rescue/preparedness plan in place? Yes / No / NR
17 Should watcher(s) be posted? Yes / No / NR
18 Is flame proof/intrinsically safe lighting to be used? Yes / No / NR

Other Precautions/Specific Conditions for Safe Operation in the Confined Space:

*NR - Not Relevant

PPC/HSSE/HTWP Form/004/4/Rev 0 Dated 11th April, 2019

 SECTION HSSE
STATUS CONTROLLED
CONFINED SPACE ENTRY PERMIT REFERENCE PPC/HSSE Permit 004

‫شركة التغليف الرئيسة‬ REVISION 0 DATE 11/04/2019

Premier Plastic Company SHEET 1

SECTION III (Permit requested by): Task In-charge

 Maintenance
 Production
 Others (Specify) ______________________________

I request for a permit for the above mentioned work at the location specified above. I have personally inspected the work place to ensure that requirements needed
as precautionary measures as mentioned above have been complied with.

Name (Person Requesting): ____________________________ Signature: ______________ Time: _____________

SECTION IV (Permit issued and authorized by):

Work shall be carried out (only) after complying with the requirements of section II and the following Signatures below.

This is valid up to (Time): ______________________________________ Date: __________________

HSSE Incharge: Name __________________________ Sign. _________________ Phone ______________

Plant Manager: Name __________________________ Sign. _______________ Phone ______________

SECTION V (Extension of Permit):

We approve the extension of the above work after personal inspection, conditions mentioned in Sec. II are ensured.

From: _____________________ hrs. To: ________________________ hrs.

Requester: Name _________________________________ Sign. ________________________ Time _____________

Issuer: Name _________________________________ Sign. ________________________ Time _____________

Authorizer: Name _________________________________ Sign. ________________________ Time _____________

SECTION VI (Closing of Permit):

The work is completed and the area has been cleaned.

Name (Person Requesting) _______________________________ Signature ________________________

(Name as in Section III)

Time ____________________ Date ____________________

To be returned to the HSSE Department after completion of work and duly closing.

Names of the persons involved in the task to be briefed by Supervisor and HSE Personnel:

PPC/HSSE/HTWP Form/004/4/Rev 0 Dated 11th April, 2019