ENCLOSED SPACE ENTRY PERMIT

Company Forms and Check Lists

Date Rev.No Prep. App. Section Page

: 03.04.01 :1 : MGV : CAP : 02 : 1 of 2

1) 2) 3)

The entry permit should contain a clear indication as to its maximum period of validity which, in any event, should not exceed a normal working day. In order to obtain a representative cross-section of the compartment's atmosphere,samples should be taken from several depths and through as many openings as possible. Ventilation should be stopped for about 10 minutes before pre-entry atmosphere tests are taken. Tests for specific toxic contaminants, such as benzene and hydrogen sulphide, should be undertaken depending on the nature of the previous contents of the space.

This permit is valid From To Location of work Reason for entry 1 PRE-ENTRY PREPARATIONS (checked by Master or responsibile officer) Has the space been segregated by blanking off or isolating all connecting Have valves on all pipelines serving the space been secured to prevent their Has the space been cleaned? Has the space been thoroughly ventilated? Pre-entry atmosphere tests: Oxygen: % vol (20%) Hydrocarbon: % LFL (<1%) Toxic gases: ppm (specify gas and PEL) Have arrangements been made for frequent atmosphere checks to be made Have arrangements been made for the space to be continuously ventilated Is adequate illumination provided? Is rescue and resuscitation equipment available for immediate use by the Has the responsible person been designated to stand by the entrance to the space? Has the officer of the watch (bridge, engine room, cargo control room) been Has a system of communicaiton between the person at the entrance and those
C:\FORMS\02_0002.PDF

hours hours

Date Date

Yes / No Yes / No Yes / No Yes / No

Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No

MT LADON

ENCLOSED SPACE ENTRY PERMIT

Company Forms and Check Lists

Date Rev.No Prep. App. Section Page

: 03.04.01 :1 : MGV : CAP : 02 : 2 of 2

Are emergency and evacuation procedures established and understood? Is there a system fr recording who is in the space? Is all equipment used of an approved type? 2 PRE-ENTRY CHECKS (checked by person responsibil for team entering space) Is Section 1 of this permit fully completed? I am aware that the space must be vacuated immediately in the event of I have agreed to the communication procedures I have agreed upon a reporting interval of__________minutes Emergency and evacuation procedures have been agreed and are understood

Yes / No Yes / No Yes / No

Yes / No Yes / No Yes / No Yes / No Yes / No

In the circumstances noted it is considered safe to proceed with this enclosed space work. Signed : ____________________________ Master/Responsible Officer ____________________________ Person carrying out work task or in charge of work team 3 The work has been completed and all persons under my supervision, materials and equipment have been withdrawn. Authorised person in charge: _______________________________________________________ Time: ____________________________________ Date: __________________________________ THIS PERMIT IS RENDERED INVALID SHOULD VENTILATION OF THE SPACE STOP OR IF ANY OF THE CONDITIONS NOTED IN THE CHECK LIST CHANGE
Notes: 1. The entry permit should contain a clear indication as to its maximum period of validity which, in any event, should not exceed a normal working day.

2. In order to obtain a representative cross-section of the compartment's atmosphere, samples should be taken from several depths and through as many openings as possible. Ventilation should be stopped for about 10 minutes before the pre-entry atmosphere tests are taken. 3. Tests for specific toxic contaminants, such as benzene and hydrogen sulphide, should be undertaken depending on the nature of the previous contents of the space.

INSTRUCTIONS :
To be filled in before each entry into enclosed spaces (including pumproom) and kept in the safety officer's file Section 5 for a period of three years. C:\FORMS\02_0002.PDF

MT LADON