Engineering company for industries

Confined Space Entry Permit

HSE Dept.

Management:- Name:- Code :-

Executive Dept. :- Supervisor :- Code :-

Part 1
Contractor :- Supervisor :- Code :-
Location :-
Work Description(Reason of entry):-

Requested by:- Date :- / / Hour:-

Procedures taken to secure the area

No Yes Equipment / Space condition N/A No Yes Equipment / Space
N/A condition
Extra ventilation needed Empty
Installed Vaporized
The Lines are isolated Flushed
Ignition Sources removed Ventilated
All the Exists are opened and cleard Cleaning Needed
Electrical isolation Gas testing req.

Part 2
No other hazard Chemical Free

 Any Condition Affects the work Progress

 Procedures required to eliminate it
 Professional Individual is required Name:- Code:-

Location is inspected and it is Allowed / Not Allowed to enter the location

Date :- Hour:-
Name:- Code:- Signature:-

Electricity has been Isolated

Part 3
Date:- / / Hour:-
Name:- Code:-
Profession:- Signature:-
Gas Testing Results
Toxic Gases
Other Oxygen % Flammable Gases Gas Type

Part 4
Result

Gas Testing done Date:- / / Hour:-

The test is considered canceled if any condition has changed
Name:- Code:- Signature:-
Required PPE
No Yes No Yes

Gloves Anti-Acid Suit

Part 5

Boots Ventilated Full Suit

Fall Arrestor Anti-Acid Bib
Respirator Mask Face and head cover
Face Shield Goggles
Other Percussions:-
Name:- Code:- Signature:-
Executive Manager aware of all required percussions and procedures
Part 6

Date:- / / Hour:- Signature:-