CONFINED SPACE ENTRY PERMIT

To identify safe work practices related to working inside a confined space or a vessel or a plant / equipment.
A. The person taking permit (permittee) to fill up.
1. IDENTITY OF THE CONFINED SPACE
2. LOCATION
3. PURPOSE OF ENTRY
4. DATE
5. VALIDITY OF CONFINED SPACE

THE ENTERY IS PERMITTED ONLY DURING DAY HOURS

6. HAS SAFETY HARNESS (FULL BODY HARNESS) WITH LIFE LINE PROVIDED?
(OTHER END OF THE LIFELINE TO BE TIED WITH SOME FIXED STRUCTURE
OUTSIDE THE BORE HOLE.)
7. HAS OXYGEN GAS TEST BEEN DONE ?
8. HAVE THE PERSONS REQUIRED TO ENTER THE CONFINED SPACE
BEEN TRAINED IN DEALING WITH THE SPECIFIED HAZARDS
9. PPE PROVIDED
10. HAS A RESQUE TEAM EQUIPED WITH EMERGENCY RESQUE DEVICES
PUT ON STANDBY

11. HAS 24V HAND LAMP BEEN PROVIDED/TORCH

12. FRESH-AIR-FLOW PROVIDED

13. GAS TESTS REQUIRED AND HAS BEEN DONE

A. OXYGEN LEVEL (19.5% - 23.5%)

O2 LEVEL LESS THAN 19.5 REQUIRES
CONTINUOUS AIR FLOW INSIDE THE BOREHOLE
----------- %( TIME-----------)

14. LIST OF AUTHORIZED PERSONS TO WORK INSIDE A CONFINED SPACE & THE RESQUE
TEAM(LIST TO BE ENCLOSED)

I have checked the above points and found conditions suitable to undertake the work.

_________________________ ____________________ ______________________

Name of the permittee Signature Designation
(Site Engineer/Supervisor)

B) The person giving permit (Issuing Authority) to fill up

The precautions and safe conditions mentioned above have been verified and the work can be started.

Name & Signature: of ________________________ _______________

issuing authority Section Incharge Jr.Manager SHE

C)Time ____________ Date____________________ at which the permit closed & filed.

______________________ ___________________________
Name of SHEO/SUPERVISOR Signature of SHEO /SUPERVISOR