Gas Test Result and

Entry Permit
Confined Space Location :
Refer to PTW No. :

Duration Activity, Start ….................

Number of CS/Manhole
End…...............
State hot work permit number (If any)
Will hot work be conducted in a confined space ?

Ventilation : Natural/freash air : Yes No Mechanical Ventilation : Yes No

Name of standby person : Competent : Yes No

Atmospheric Test : To be filed by Authorized Gas Tester (AGT)
Pengetesan Atmosfer : Diisi oleh AGT
Times/ Name/ Signature of AGT
O2 (%) LEL (%) CO (PPM) H2S (PPM)
Waktu Nama/ Tanda tangan AGT

Entry and Exit Log (Filled by Hole Watcher) Name of Hole Watcher:
Log Masuk dan Keluar (Diisi oleh Hole Watcher) Nama dari Hole Watcher:
Name of Entrant/ Time In/ Time Out/ Time In/ Time Out/ Signature/
Nama orang yang masuk Jam Masuk Jam Keluar Jam Masuk Jam Keluar Tanda Tangan