Scribd
Upload
18 views

Confined Space Entry Permit Form Format PDF

Uploaded by

Md Imroj Ali
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
18 views

Confined Space Entry Permit Form Format PDF

Uploaded by

Md Imroj Ali
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 6

Annexure –K

CONFINED SPACE ENTRY PERMIT FORM


Date: Work Shift: Day/Night

Name of the Work:

Client: BMC Zone/Ward:

Contractor:

1. Site and Task Information

Section/Stretch Number and Name

Upstream manhole No. Downstream Manhole No.

Present
Designation Name
(Y/N)

Contractor’s Site Engineer

Contractor’s Safety Officer/ Engineer

Contractor’s Site Supervisor

Description of the work for which entry permit is sought :

2. Emergency Standby Vehicle Check

Activity Detail Checked/Present

Vehicle Registration No.

PUC valid (till)

Vehicle fuel level

Vehicle running condition

269
Activity Detail Checked/Present

Driver’s Name

Driver’s Mobile No. Checked by calling

Driver instructed

Nearest Hospital Details:

Contact No. of Hospital :

Driver must be instructed to be in the vehicle & be alert till the entire duration of the confined space activity.

Driver must be instructed NOT to keep his mobile busy during the entire duration of the confined space
activity.

3. Air Quality Checks

Gas Checked Before Ventilation After Ventilation


(safe limit) Value MH No. Time Value MH No. Time

Oxygen (19.5% to 23.5%)

H2S (max 10ppm)

Flammable gases (max 5%LEL)

Carbon Monoxide (max 30ppm)

Others ()

4. Gas Monitor Details

Name of Manufacturer :

Gas Monitor Serial Number :

Calibration Status :

Calibrated for the Gases :

Validity of Calibration :

Response test date for Gas Monitor :

270
5. Ventilation System

Ventilation System : Blower/Fan/any other specify__________________________

No of Equipments (Nos.) :

Capacity of System (HP) :

Installed at (Manhole No.) :

Flow Direction (In/out) :

6. Isolation of the Confined Space

Activity Status (Y/N)

Plugging

Stanching

Sewage Flow Control /Pumping

Harmful Substance Present

Warning Signs/Notices/ Appliances in place

Manhole Opened at (Time)

Manhole properly barricaded

7. Personnel Protective & Safety Equipment Checks

Equipment Status Quantity

Gas mask

Breathing Apparatus

Safety harness with rope

Safety Shoes

Safety Helmet with lamp

Abrasion resistant hand gloves, Nose Mask

271
Equipment Status Quantity

Protective Clothing

Communication Device

Winch Pulley System

Rescue Equipment

Ventilation Equipment

Non Spark Torch

First Aid Kit with medicines

Any Other

8. Other Safety Measures Checks

Safety Measure Status (Y/N)

Area properly barricaded

Manhole Jalis Provided

Work in progress and other warning Signs

No Smoking Warnings

Any other

9. Confined Space Entry Workers Information

Persons seeking entry into confined space

Total number of persons Tentative duration of stay in


confined space
(In words & numeral)

Checked Vaccination status of all workers entering in confined space (YES/NO)

272
Sr. Age Medically Fit
Name Time of Entry Time of Exit
No. (yrs) (Yes/No)

Attendance:

Client’s Representative Contractor’s Representative


(Name & Signature) (Name & Signature)

This is to certify that all the persons entered in the confined space have come out of the confined space as
of ____________ (time) and no further entry is required at this point of time.

Contractor’s Contractor’s
Safety Officer/Engineer Site Engineer

273
10. Work Closure Checks

All equipment/ tools removed (YES/ NO)

Obstructions removed and Flows restored (YES/


NO). If no; pl record reasons
Manhole covers properly replaced and manholes
securely closed (YES/ NO). If no; pl record reasons
and measures taken for preventing mishap

Site cleaned/ cleared (YES/ NO)

11. Emergency Event Occurrence

Has any Event(s)/Emergency(s) occurred


(Yes/No)
If “YES” then, Nature of Event(s)/Emergency(s):

This is to certify that the team entering in confined space is trained & briefed to work in the confined space
and this confined space is safe for entry and carrying out of the task.

Contractor’s Contractor’s
Safety Officer/Engineer Site Engineer

274

You might also like