Confined Space Entry Permit

TRS-HS-FRM-0059

General Information

Facility/Program/Project Permit No.

Contractor Date Date

Permit Receiver Permit Receiver’s Contact No.

No. Item

1. Location of Space

2. Description of Work to be Done

3. Equipment to be Used Inside the Space

4. Isolation of Confined Space

5. The Items Below Have Been Isolated or Prepared Safe Yes N/A
Pipelines (water, steam, gases, raw material, product, etc.) ☐ ☐
Mechanical and/or electrical drives ☐ ☐
Electrical supply services (including batteries and emergency backup) ☐ ☐
Sludges, deposits, wastes ☐ ☐
Locks and tags securely attached to isolation points ☐ ☐
Warning signs posted ☐ ☐
Other (specify): ☐ ☐
6.
Atmosphere Monitoring
(Acceptable Limits: Oxygen 19.5 – 23.5%; LEL less than 10%; other contaminants as per SDS)
Testing Frequency Required:

Date Time Oxygen (%) LEL (%) CO, H2S Tester’s Signature

6.1

6.2

6.3

6.4

6.5

6.6

6.7

6.8

6.9

6.10

6.11

6.12

Confined Space Entry Permit( TRS-HS-FRM-0059)

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No. Item

7. Personal Protective Equipment (PPE) Required

The following PPE must be worn:
7.1
Foot protection Yes N/A

7.2
Eye protection (safety glasses, full face shield, other – specify) (delete that which is inapplicable) ☐ ☐

7.3
Hearing protection ☐ ☐

7.4
Hand protection (specify type) ☐ ☐

7.5
Safety helmets ☐ ☐

7.6
Protective clothing (specify if other than normal work wear) ☐ ☐

7.7
Safety harness – with or without safety line (delete that which is inapplicable) ☐ ☐

7.8
Air-purifying respirators ☐ ☐
Hot Work
8. Yes N/A
Hot work is allowed inside the space:
8.1 Combustible materials removed from the area or made safe ☐ ☐
8.2 Drains within 49 feet (14.9 meters) covered with fireproof blanket ☐ ☐
8.3 Appropriate type and number of fire extinguishers at worksite ☐ ☐
8.4 A water hose run to job and tested and/or left running ☐ ☐
Sparks from work more than 6.5 feet (2 meters) above floor level to be completely enclosed by suitable
8.5
enclosure
☐ ☐
8.6 Welding machine earthed directly to equipment being welded, as close to the welding point as possible ☐ ☐
8.7 Power leads not draped over pipelines, steelwork, or access ways ☐ ☐
8.8 Electrical trace on pipes isolated ☐ ☐
Chemical Substances (data as required)
9. Yes N/A
Only those chemical substances listed below may be taken into the space:

9.1 ☐ ☐
9.2 ☐ ☐
9.3 ☐ ☐
9.4 ☐ ☐
9.5 ☐ ☐
10. Confined Space Entry Permit Checklist Yes N/A

10.1 Access ways secured in an open position? ☐ ☐

10.2 Adequate supply of fresh air available for the duration? ☐ ☐
10.3 Adequate access and egress provided to access ways/entrances? ☐ ☐
10.4 Adequate access and egress provided to internal work platforms? ☐ ☐
10.5 Ladders required for internal access? ☐ ☐
10.6 Personal monitors required to be used by entrants? ☐ ☐

Confined Space Entry Permit( TRS-HS-FRM-0059)

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Confined Space Entry Permit
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No. Item

10.7 A confined space rescue plan in place? ☐ ☐

10.8 Entry and emergency instructions have been given to attendant/standby person(s)? ☐ ☐
10.9 Rescue and emergency procedures have been posted: ☐ ☐
Stand by Person
11.
I understand the work to be done within the confined space plus my duties as attendant/standby person.

Name: Contact No.

Name: Contact No.

Confined Space Entry Team:

I/We understand the requirements required for entry and work in the confined space described and the Trained
12. protective measures and equipment to be used.
Name Company Signature Date Time Yes N/A

12.1 ☐ ☐
12.2 ☐ ☐
12.3 ☐ ☐
12.4 ☐ ☐
12.5 ☐ ☐
12.6 ☐ ☐
12.7 ☐ ☐
12.8 ☐ ☐
12.9 ☐ ☐
12.10 ☐ ☐
Supervisor Responsible for the Work
13. The confined space described above is in my opinion in a safe condition for the work to proceed, provided that the precautions noted are fully
ensured.
Supervisor In-Charge Name Contact No. Signature Date
Entry Supervisor

14. Permit Validity

Permit Valid from a.m./p.m. on ( / / ) Date to a.m./p.m. on( / / ) Date.

15. Approval
Approvals Name Contact No. Signatures Date
Contractor HSE Manager
(Authorized Permit Issuer)

Contractor Project Manager or Designee

(Verified & confirmed)

Confined Space Entry Permit( TRS-HS-FRM-0059)

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Confined Space Entry Permit
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THIS DOCUMENT TO REMAIN AT ENTRY POINT

Contractor Approved Work Permit No.:

Permit Validity a.m./p.m. on (date) to a.m./p.m. on (date)

Supervisor Responsible for the
Contact number
Work
Permit Receiver Contact number

Authorized Permit Issuer Contact number

Job Description

Precautions

Atmosphere Testing
Frequency of Tests
Continuous Monitoring Yes No
Minimum 2 Hourly
Oxygen
%LEL
Date Time Tester Max 23.5% CO, H2S Other Other
<10%
Min 19.5%

Authorization
The confined space described above is in my opinion in a safe condition for the work to be done, provided that the precautions
above are fully observed.

Name and Signature of Atmosphere Tester Date Time Valid for (hours)
Personnel Entering Confined Space Gas Testing
Time Test Test Gas
Name Company Signature Time In Tester’s Signature
Out Result Time Tested

Personnel Entering Confined Space Gas Testing

Confined Space Entry Permit( TRS-HS-FRM-0059)

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Time Test Test Gas

Name Company Signature Time In Tester’s Signature
Out Result Time Tested

Duties of an Attendant/Standby Person

Maintain continuous communication with personnel in the space. This may be verbal, visual, or physical (such as rope signals).
Confirm that all personnel sign the permit before entering the space and after leaving it.
Verify that conditions specified on the permit are in compliance.
Prevent the fouling of airlines and/or lifelines when these are used. Have a process available to call for assistance and/or raise the alarm.

While personnel are in the space, you must remain at your post except to get help/raise the alarm in an emergency. If for any reason you must leave your
post, then all personnel within the space must exit the space for the duration of your absence, or you must be relieved by another attendant/standby
person. In the event of an emergency, your first duty is to raise the alarm and initiate emergency procedures. DO NOT attempt to rescue personnel in the
space. Order personnel to exit the space if hazardous conditions are observed; if any person in the space exhibits behavioral or other symptoms; if for any
reason you can’t perform your duties; or when the emergency evacuation alarm sounds.

All permits are cancelled in the event of an emergency on site and must be reissued prior to reentry into the space.

Attendant/Standby Person
I understand the work to be done within the confined space plus my duties as attendant/standby person.
Print Name Signature Date Time

Persons Entering Confined Space

I have read and discussed this permit and I am fully aware of and will observe all of its precautions.
Time Complete
Print Name Date Signature Time Exited Signature
Entered Yes/No

Job Complete and Permit closeout and remarks

Remarks:

Permit Closeout Name Date Time

Entry Supervisor
(Completion of Task)
Authorized Permit Issuer
(Permit closeout)

Confined Space Entry Permit( TRS-HS-FRM-0059)

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