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HAZARDOUS WORK PERMIT

(To be completed by SHLC trained staff only)
No Register :
STEP 1

Exact Location of Job (PRINT) :

STEP 2

Description of Work (PRINT) :

Gas Free Certificate Required ?
YES

UNSURE

Hot Work Permit Required ?
NO

YES

STEP 3

Confined Space Entry Permit Required ?

NO

YES

STEP 5
STEP 4

STEP 6

Combustibles
Oxygen
Hydrogen Sulphide
Carbon Monoxide

Space Tested (PRINT)

By (PRINT)
Position (PRINT)

CONFINED SPACE ENTRY PERMIT

_________________________________

________________________________________________________

THESE PRECAUTIONS MUST BE CONSIDERED
PRIOR TO ANY WORK COMMENCING

GAS FREE CERTIFICATE

______________________________________
Gas free work will be done by
"Authorised Gas Free Assessor (AGFA)"
Gases Tested
Sampled

STEP 8

HOT WORK PERMIT

To be completed by OH&S/ AGFA (ONLY)

NO

STEP 7

Yes

THESE PRECAUTIONS MUST BE CONSIDERED
PRIOR TO ANY WORK COMMENCING

No

1)
2)
3)
4)

Are fixed fire systems in service ?
Portable fire extinguisher required.
Running hose water required.
Combustible materials to removed (10 mtr radius). Check if construction is combustible
5) Area below job to be cleared.
6) Fire blanket required at job site.
7) Barricading around job site required
8) Hot Work Overed signs required.
9) Phone or 2 way radio required at job site.
10) Isolation required - (see special instruction
and list Isolation Permit No.)
11) Special Instructions to be read.
12) Will starting this work create a hazard
with other work in progress ?
13) Fire watch required.
14) Advise emergency services.
15) Area tested for combustibles. Record results……

1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)

Self Contained Breathing Apparatus.
Airline respirator.
Combination organic vapour
and particulate filter respirator.
Disposable particulate respirator.
Forced air ventilation/extraction required.
Safety observer required.
Safety harness to be worn.
All equipment to be intrinsically safe (electrically spark free).
Phone or 2 way radio required at job site.
Isolation required - (see special instructions
and list Isolation Permit No.)
Special instructions to be read.
Will starting this work create a hazard
with other work in progress ?
Complete details on reverse side.
Emergency Exit / Apparatus

Yes

No

See
Flowchart

See
Over

Signature
I have read and understand the requirements
Of this permit.

SPECIAL INSTRUCTIONS
VALID UNTIL

STEP 9

ISSUED BY :

Time
:
:
:
:

Initial

ACCEPTED BY :

Dept. Name

Dept. or Contractor Company Name

Name (PRINT)

Name (PRINT)

Signature

Signature

NAME (PRINT)

Permite Transferable to a
Maximum of …….. 24 Hours
but must never exceed

GAS FREE
CERTIFICIATE
DATE and TIME

267068746.xls

Permit
Valid From

Date

Date

Permit Expires
Time
:
:

Time

:

Initial

INITIAL

Permit must remain
at job site while work
is in progress and then
retained on file for
auditing purposes.

CHECK INTERVALS BY: During Job After Job : : : For a period o Signature On : Off : : : : : : : : FIRE WATCHER Name (Print) PERSONS ENTERING CONFINED SPACE Entry : : : : : : : : Exit : : : : : : : : : : : : : : : : : : : : : : : : : : : : FIRE WATCHER MUST BE TRAINED IN THE USE OF EXTINGUISHERS AND FIRE HOSES AND MUST KNOW HOW TO SOUND THE ALARM AS APPROPRIATE : : : : : : ACCEPTANCE and TRANSFER of PERMIT : : : : : : : : : : : : : : : : The area is now clean : : The area/equipment is safe : : The area/equipment is operational : : : : : : : : No CHECK INTERVALS BY: OBSERVER Name (Print) No No During Job Signature Signature Name (Print) : On : Off : : : : : : : On : Off : : : : CANCEL HAZARDOUS WORK PERMIT Time & Date : Print Name : Signature : : / / Is there a work Procedure 267068746.xls Name (Print) .