Darwin International Airport Confined Space Entry Permit
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4DIA Project No.
Permit No.
Darwin International Airport
Confined Space Entry Permit
FORM‐P004
Safety is paramount at DIA and this permit application has been designed to ensure that all safety aspects of the confined
space entry work have been considered and actioned.
All contractors, tenants or DIA staff are required to be in possession of a permit before commencing any confined space entry
activity. This application is required for all excavation and trenching, including holes for posts and signs.
PART 1 – APPLICANT DETAILS
Applicant Name:
Phone:
Business Name:
PART 2 – ISOLATION
Location of work:
_________________________________________________________________________
Pit No:
__________________________________ Date of work:__________________________
Description of work:
_________________________________________________________________________
Space needs to be Isolated from
_________________________________________________________________________
(Location / method)
Water/gas/steam/chemicals
_________________________________________________________________________
Mechanical/electrical drives
_________________________________________________________________________
Auto fire extinguishing systems
_________________________________________________________________________
Hydraulic/electric/gas/power
_________________________________________________________________________
Sludge/deposits/wastes
_________________________________________________________________________
Locks and/or tags have been
□
□
Yes
No
affixed to isolation points?
PART 3 – ATMOSPHERE
The atmosphere in the confined space has been tested:
Results of test:
Oxygen
_________________________________ %
Flammable gases
_________________________________ % LEL
_________________________________ % LEL
Other gases:
_________________________________ ppm (less than ppm)
_________________________________ ppm (less than ppm)
Other airborne contaminants:
_________________________________________________________________________
_________________________________________________________________________
|
DARWIN INTERNATIONAL AIRPORT
Airport Management Centre
|
|
T: +61 8 8920 1811
F: +61 8 8920 1800
E: .au
|
|
PO Box 40996 Casuarina NT 0811
1 Fenton Court Eaton NT 0820
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Document Issue Date: 09/05/2014
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