KHURSANIYA GAS PLANT PROJECT

Consolidated Contractors Company W.L.L

CONFINED SPACE ENTRY FORM

CONFINED SPACE ENTRY PERMIT NO:

TIME
DESCRIPTION OF THE CONFINED SPACE e.g VESSEL / PIPE NO. LOCATION DATE FROM TO

SUPERVISOR :

WORKERS NAME :

FULL DESCRIPTION OF WORK :

SPECIFIC HAZARDOUS TASKS

WELDING / GRINDING / CUTTING ELECTRICAL CLEANING / SWEEPING / VACCUMING OTHER EXPLAIN
PAINTING OR CLEANING WITH SOLVENTS

CHEMICAL MAINTENANCE INSPECTION

SCRAPING / REMOVING RESIDE ERECT SCAFFOLDING

CHECKLIST FOR ISOLATION AND UNAUTHORIZED ACCESS PREVENTION

YES
EXTERNAL BARRIER(S) IN PLACE MECHANICAL LOCK OUT / TAG OUT ELECTRICAL LOCK OUT / TAG OUT LINES / PIPES DISCONNECTED LINES / PIPES BLINDED / SPADED WARNING SIGNS TRAINING INSTRUCTION GIVEN
INTIAL ATMOSPHERIC TESTS PERFORMED

NO

N/A

INITIAL

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
HAZARD TESTED ACCEPTABLE RANGE READING DATE & TIME TESTER INITIALS ACCEPTABLE
YES NO

% OXYGEN % L.E.L. FLAMMABLE GAS H2S Radiological hazard

ABOVE 20% N.A. P.E.L. = N.A. <10%

% N.A. PPM = N.A. DAC Capacity:___________________________ Date:__________________________ Capacity:___________________________ Date:__________________________

Issuers Signature:__________________________ Receiver's Signature :_______________________

PP710_SCSE_864_2 (Front)