Form 3 Confined Space Entry Permit
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4Form #3
Confined Space Entry Permit
1.
Location of work:
6.
Hot Work:
Description of work:
Area clear of all combustibles including atmosphere
..Yes / No
List type of appropriate fire prevention equipment
a va ila b le:
.
Outside contractors assigned & company represented:
Suitable access and exit
Yes / No
Equipment required in good condition
Yes / No
Hot work is permitted
Yes / No
Hot work permit issued
Yes / No
2.
Isolation:
7.
Personal Protective Equipment:
Space needs to be isolated from:
The following safety equipment shall be worn:
TYPE
Water/gas/oil/steam/chemicals
Yes / No
Respiratory protection
Yes / No
Mechanical/electrical drives
Yes / No
Harness/life line
Yes / No
Auto fire extinguishing systems
Yes / No
Eye protection
Yes / No
Hydraulic/electrical/gas/power
Yes / No
Hand protection
Yes / No
Sludge/deposits/wastes
Yes / No
Overalls / wet weather gear
Yes / No
Locks/tags have been affixed to
Hearing protection
Yes / No
isolation points
Yes / No
Safety Hard Hat
Yes / No
Other _____________________________________
__________________________________________
3.
Atmosphere:
8.
Other Precautions:
The atmosphere in the confined space has been tested:
Results of tests:
Warning notices/barricades
Yes / No
Oxyg en
..% LEL
All persons competent
Yes / No
Fla m ma b le Ga ses:
.. % LEL
Ventilation
.. % LEL
require me nts
Other Gases
..
p p m (less tha n
.p p m )
PORTABLE ELECTRICAL EQUIPMENT
p p m (less tha n
..p p m )
Other atmospheric
Inspected as in good order
Yes / No
c o nta m ina nts:
Current inspection label attached
Yes / No
RCD provided and tested
Yes / No
If the oxygen level is less than 20.9% further investigation is
required. Area is to be either ventilated and re-tested prior
to entry. Where levels remain the same breathing apparatus
MUST be worn
4.
Use of chemical agents:
9.
Emergency Response Procedures / equipment
No chemical agents other than those listed below may be
First aider notified of confined space entry
Yes / No
taken into confined space:
Water / fire hose required during work
Yes / No
1.
2.
Mobile plant to be excluded from area
Yes / No
3.
4.
Other_____________________________________
5.
6.
__________________________________________
5.
Job Safety Analysis
10. Stand-by Personnel
Stand-by personnel/requirements
Has a job safety analysis been completed and what risks
have been identified
Yes / No
Observer to be in voice contact
Yes / No
List risks (on attached page)
Rescue equipment available & ready
Yes / No
Other______________________________________
___________________________________________
Signed by: Competent person/Permit Issuer
(Print Name)
________________________________________________
______________________________________________
Date:___________________________________________
______________________________________________
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