SUPPORTING CERTIFICATE OF

CONFINED SPACE ENTRY

FORM 3102 REV 2

BRANCH POSCO - CILEGON SERIAL No.

Section I
LOCATION OF
CONFINED SPACE

Section 2
WORK TO BE DONE

Section 3 Permit to Work Number

RELATED PERMITS Permit Date
Section 4 Reasonably practical to conduct work without entry into Confined Space YES / NO
CONFINED SPACE Potential for oxygen enrichment YES / NO
HAZARDS Potential for oxygen deficiency YES / NO
Potential for presence of flammable subtances YES / NO
(Delete YES / NO as applicable) Potential for presence of toxic substances YES / NO
Potential for ingress of liquid / gas from external sources YES / NO
Potential for solid materials which can flow YES / NO
Potential for temperature extremes YES / NO
Access / egress hazards under normal conditions YES / NO
Section 5 Risk Assessment completed YES / NO
SELECTION OF Supervision required: constantly, hourly, commencement of work Specify
CONTROLS Current BOC Medical Certificate for Entry YES / NO
(Delete YES / NO as applicable) Competent standby man required YES / NO
Communication between those inside confined space YES / NO
Communication between standby man and those inside confined space YES / NO
Communication to summons help YES / NO
Isolation from gases, liquids, flowing materials YES / NO
Isolation from mechanical and elecrical equipment YES / NO
Authorised Gas Analysis on atmosphere before entry YES / NO
Frequency of re-analysis of Authorised Gas Analysis agreed YES / NO
Atmosphere purged before entry YES / NO
Constant purged of fresh air (blowers) YES / NO
Personal monitor to be worn YES / NO
Location of atmosphere monitor agreed YES / NO
Respiratory Protective Equipment required YES / NO
Prevention of ignition from tools, equipment and static electricity YES / NO
Extinguishers placed at access and egress points YES / NO
Lighting required YES / NO
Safe and adequate access and agress YES / NO
Harness to be worn YES / NO
Effective rescue equipment available for the total duration of work YES / NO
Emergency plan in place and understood by all YES / NO
"NO UNAUTHORISED ENTRY" signs required YES / NO
Section 6 Permit to Work Number
CERTIFICATE Authorised Person's Signature
ISSUE Date
Time
Section 7 Permit to Work Number
CERTIFICATE Authorised Issuer's Signature
RECEIPT Date
Time
Section 8 Permit Issuer's Signature: Authorised Person's Signature:

CERTIFICATE
CANCELLATION Date: Time Date: Time: