Section 1

Permit No.       W/O No. (If applicable)      

Section 2: General Information

Contract       Date      
Confined space entry by Choose an item. Sub-Contractor Details      
Work Description      
Work Location      
From To From To
Date of Work Time of Work
                       
Duration of Work      
Other PTW Interface Yes Choose an item. Choose an item. No

Section 3: Air Quality Test

Date       Time      
Instrument used       Brand & Model #      
Date of Calibration       Calibration Company      
Oxygen Level       (Safe Limit 19.5% to 23.5%) Flammable gas       % ( Under 10% LFL)
Carbon Monoxide       ( <35 PPM for 8 hours) Hydrogen Sulphide      
Carried Out by       Designation      
Mobile       Signature

Section 4: Isolation
Choose an item. WO #      
Is Isolation Required Yes No
Choose an item. WO #      

Section 5: Pre-Task Check (Mandatory Work Site Inspection Required) Yes N/A Comments
Competency of Operatives      
Confined Space training certificate evidenced      
All the required isolations in place with LOTO applied      
Purging of space implemented      
Adequate ventilation of space      
Continuous ventilation of space required and provided      
Rescue equipment required and available      
“Confined Space rescue” trained people monitoring the activity      
Provisions for two way communication provided      
Breathing Apparatus required and available      
Emergency response action briefed      
Sufficient illumination available      
Proper access available for entry/exit and also for rescue operations      
Mechanism implemented to prevent unauthorised entry      
Appropriate signs/ barricade provided      
Fire fighting equipment available (hot work inside confined space)      
Satisfactory visual inspection conducted on equipment/ tool/ machine      
Implementation of “No Smoking” Policy      
Risk Assessment briefed to all the operatives performing this task      
This task does not involve any lone working      
Mechanism implemented to prevent cross contamination (Tank Cleaning)      
Visual inspection of PPE’s are satisfactory      

Section 6: Confined Space Entry

Sign In Sign out Stand-By/ Rescue
Name Signature Name Signature Name Signature
                 
                 
                 
                 
                 

Section 7: PTW Authorization (Permit Issuer)

Based on the information provided in section (2) and the due diligence carried out in section (3), (4) & (5) I am
authorizing this PTW given that all the precautions are adhered to.
Issuer Name       Mobile      
Designation & Company       Signature

Section 8: PTW Acceptance (Permit Receiver)

I understand the hazards associated with work and its precautions as stated during the Risk Assessment briefing. I am
accepting the conditions of this PTW and I will be responsible for ensuring that all stated HSE precautions are in place
and adhered to.
Receiver Name       Mobile      
Designation & Company       Signature

Section 9: PTW Extension

The time limits of this PTW have been extended as indicated below. All the initial stated HSE precautions shall be
applicable. Extended time limits are as follows:
From To From To
Extended date Extended time
                       
Name       Signature

Section 10: Post-Task Check (Mandatory Work Site Inspection Required) Yes N/A Comments
Area returned to its normal condition      
Tools/equipment/ material/ barricade/ signs removed      
Reinstate any isolations      
Waste generated removed from the work site      
Any Manhole covers/ Tank covers etc. closed      

Section 11: PTW Close-Out

We declare that the task described above and to which this PTW is issued has been completed & the work area,
associated systems/equipment are returned to its normal state

PTW Issuer Signature PTW Receiver Signature

Section 12: PTW Cancellation

Reason for cancellation      
Cancelled by       Designation      
Date       Signature