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CONFINED SPACE ENTRY PERMIT

Name of Project :
Date:

Permit No. :
Work location :
Type of Work to be done : Storm water Manhole cleaning

Personal Protective Equipment


Required (PPE)

H2S Monitor

Hard Hat

Goggles/ Safety Glass

Safety Shoes

Hearing Protection

Coverall

Safety Harness

Air Respirator

SAFETY PRECAUTION

Sl.No.

Safety Measures

Work area been inspected and reasonable precautions taken to ensure that no
potential Hazard exists

Necessary barricades,Standby person, Flag man and warning signs in place.

Workers been safety Inducted

Tool Box Talk (TBT) meeting being held

Job Safety Analisis (JSA) meeting being held

Emergency Procedures been discussed to the workers

Emergency Vehicle and First Aider available

Job Rotation in place

YES

NO

Permit Rquested by:

I understand and agree that no work is permitted other than that specified on this permit. I have check both permit and the job, and understand the
and precaution to be followed in completing the work
Engineer/ Supervisor

Signature :

Date :

Signature :

Date :

Signature :

Date :

Checked by:
Safety Officer

Issued by:
Project Engineer

PERMIT CLOSE OUT


Close out requested by:
I have closed the work;removed all materials and made the area safe
Engineer/ Supervisor

Signature :

Date :

Signature :

Date :

Close out area checked by:


Safety Officer

Revision 0

AGP/HSE/SF/029

Permit Closed by:


Project Engineer

Revision 0

Signature :

Date :

AGP/HSE/SF/029

Remarks

tand the nature and extend of the work


Time :

Time :

Time :

Time :

Time :

Revision 0

AGP/HSE/SF/029

Time :

Revision 0

AGP/HSE/SF/029