This document is a confined space entry permit that details health and safety requirements for entry. It contains information such as the permit number, location, supervisor's name, date and time of entry/expiration, description of work, equipment used, atmospheric monitoring records, checklist of safety requirements verified like ventilation, isolation of hazards, rescue equipment, and a log to record personnel entering and exiting the confined space. Personnel must sign to acknowledge understanding of instructions before entry is allowed. [/SUMMARY]
This document is a confined space entry permit that details health and safety requirements for entry. It contains information such as the permit number, location, supervisor's name, date and time of entry/expiration, description of work, equipment used, atmospheric monitoring records, checklist of safety requirements verified like ventilation, isolation of hazards, rescue equipment, and a log to record personnel entering and exiting the confined space. Personnel must sign to acknowledge understanding of instructions before entry is allowed. [/SUMMARY]
This document is a confined space entry permit that details health and safety requirements for entry. It contains information such as the permit number, location, supervisor's name, date and time of entry/expiration, description of work, equipment used, atmospheric monitoring records, checklist of safety requirements verified like ventilation, isolation of hazards, rescue equipment, and a log to record personnel entering and exiting the confined space. Personnel must sign to acknowledge understanding of instructions before entry is allowed. [/SUMMARY]
This document is a confined space entry permit that details health and safety requirements for entry. It contains information such as the permit number, location, supervisor's name, date and time of entry/expiration, description of work, equipment used, atmospheric monitoring records, checklist of safety requirements verified like ventilation, isolation of hazards, rescue equipment, and a log to record personnel entering and exiting the confined space. Personnel must sign to acknowledge understanding of instructions before entry is allowed. [/SUMMARY]
Mohammed Abdulmohsin Al-Kharafi & Sons LLC- DS197/1
CONFINED SPACE ENTRY PERMIT
Note: - This permit is valid only for one shift i.e. Maximum 12 hours and cannot to extended. PERMIT NO: PROJECT/LOCATION: SUPERVISOR RESPONSIBLE FOR WORK: PERMIT ISSUE DETAILS Date: Time: PERMIT EXPIRY DETAILS Date: Time: DESCRIPTION OF WORK:
EQUIPMENT TO BE USED INSIDE CONFINED SPACE:
WATCHER’S NAME: YES NO YES NO TRAINED PPE REQUIREMENT LOG SHEET EMERGENCY COMMUNICATION
PERSONNEL PERMITTED ENTRY
Trained Trained NAME NAME YES NO YES NO
ATMOSPHERE MONITORING DATE TIME OXYGEN % COMBUSTIBLE GAS % TESTERS SIGNATURE
OXYGEN LEVEL – MIN. 19.5%, MAX. 23.5% COMBUSTIBLE GAS – MAX 10% L.E.L
CONFINED SPACE ENTRY PERMIT CHECKLIST YES NO N/A
All manhole secured in an open position? Adequate supply of fresh air available for the duration of entry? Adequate access and egress provided to manhole/entrances? Is oxy/acetylene equipment required? Page 1 of 3 DS 197/1 MAK/ HSEF – 003 Revision - 00, Dated: 09.10.2019 Mohammed Abdulmohsin Al-Kharafi & Sons LLC- DS197/1
CONFINED SPACE ENTRY PERMIT
(If the previous is yes – complete additional requirements information listed below) Is welding required in the confined space? (If yes – complete additional requirement information listed below) Has gas testing been completed? Are levels satisfactory? Have entry and emergency instructions been given to entrants and manhole watcher? Has the type of adjacent works been considered? (Additional break) Have combustible materials been removed from the area? Are fire extinguishers required to be located at access locations? Are ladders required for internal access? (If yes – complete additional requirements information listed below) Is adequate illumination available and provided? Are all pipelines, electrical sources, etc. isolated, tagged and witnessed? Is the type of work being done is likely to cause hazard? E.g. Fume Is there any animal or insect in confined space? Is mechanical ventilation required? Has a responsible person been designated to stand by the entrance to the space? Is there a system for recording who is in the space? (Entry/Exit Log sheet) Caution signage’s and Emergency Contact Number Displayed at confined space area? Is there rescue and first aid equipment available for immediate use at the entrance to the space?
Additional Requirements/Special Conditions?
RECEIPT I hereby declare that I have read and understood the instructions given above. No attempt will be made by me or persons under my control to carry out any work other than that specified. Name & Signature of Authorised Person (Direct Company: Time: Supervisor): Date: I have verified that the documentation, testing and health and safety arrangements are adequate to start the Confined Space Work
Name & Signature of Company: Time:
SENIOR/AUTHORISED/COMPETENT Person (Engineer) Date:
Name & Signature of HSE Person Company: Time :
Date : CLEARANCE I hereby declare that the work for which this permit was issued is now COMPLETED/SUSPENDED and all persons under my control have been withdrawn and tools removed. Name & Signature of Company: Time: SENIOR/AUTHORISED/COMPETENT Person (Engineer) Date:
CANCELLATION. THIS PERMIT IS NOW CANCELLED:
Page 2 of 3 DS 197/1 MAK/ HSEF – 003 Revision - 00, Dated: 09.10.2019 Mohammed Abdulmohsin Al-Kharafi & Sons LLC- DS197/1
CONFINED SPACE ENTRY PERMIT
Confined Space Entry Monitoring Log Permit No: Date Issued: Date Expires:
Entry Commence Time: Entry Finish Time:
Confined Space Location and Work Activity:
Safety Watch Name: Signature:
Time In Name (Print) ID Number Signature Time Out Signature
Time Activity Completed: Date:
All personnel confirmed removed from confined space by:
1) SPOUSES TEODORO and NANETTE PEREÑA - Petitioners - vs. SPOUSES NICOLAS and TERESITA L. ZARATE - PHILIPPINE NATIONAL RAILWAYS - and The COURT OF APPEALS
