PERMIT TO WORK - CONFINED SPACE

1. General Details

Permit Number: CS-2023-054 Company Name: Citywide Plumbing Solutions Site Location: 12 Smith Street, Richmond, VIC Date of Issue: 25/10/2023 Time of Issue: 07:00 AM Time of Expiry: 07:00 AM (26/10/2023)

2. Confined Space Description

Location of Space: Rear Bore, Stormwater Pit 2 Type of Space: Bore / Pit Purpose of Entry: Pump maintenance and debris removal

3. Hazard Identification

• Oxygen deficiency or enrichment
• Flammable or explosive atmosphere
• Toxic gases or vapours (Hydrogen Sulphide)
• Engulfment (e.g., liquids, solids, grain)
• Mechanical or electrical hazards
• Temperature extremes
• Noise or vibration
• Biological hazards
• Other: Slippery surface

4. Risk Control Measures

Atmospheric Testing:

• Oxygen: 20.8 % (Safe range 19.5% - 23.5%)
• Flammable Gases: 0 % LFL
• Toxic Gases: 0 ppm
• Test Time: 06:55 AM
• Tester Name: J. Smith

Cleaning and Preparation:

• Space drained and purged
• Space cleaned of residues
• Continuous ventilation provided (Blower Fan running)

5. Isolation Procedures (Lock Out Tag Out)

Energy Source	Isolation Point	Lock Applied? (Yes/No)	Tag Applied? (Yes/No)	Initials
Electrical	Main Switchboard MSB-02	Yes	Yes	JS
Mechanical	Pump Impeller	Yes	Yes	JS
Pneumatic	N/A	N/A	N/A
Hydraulic	N/A	N/A	N/A
Steam/Water	Inlet Valve	Yes	Yes	JS
Other	N/A	N/A	N/A

6. Personnel and Roles

Authorised Person (Issuer): J. Smith [Signature]

Authorised Entrants:

1. M. Jones [Signature] Time In: 07:15 Time Out: 11:30
2. A. Brown [Signature] Time In: 07:15 Time Out: 11:30

Standby Person: K. Lee [Signature] Location of Standby Person: Top of pit, near ventilation fan

7. Emergency Equipment

• Tripod and winch / retrieval system
• Full body harness (one per entrant)
• Lifelines attached
• Emergency breathing apparatus (SCBA or airline) - Not required per risk assessment
• First aid kit
• Fire extinguisher
• Communication equipment (Two-way radio)
• Emergency lighting - Daylight operation

8. Rescue Plan

Brief description of rescue procedure: Standby person to use winch to retrieve entrants via harness lifeline. Do not enter pit. Call 000 immediately.

9. Display and Acceptance

I acknowledge that I have read and understood the controls listed on this permit and I am authorised to enter.

Lead Entrant Signature: M. Jones Time: 07:10 Standby Person Signature: K. Lee Time: 07:10

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10. Permit Closure

Work Completed: YES Reason if Incomplete: N/A All personnel accounted for: YES All locks and tags removed: YES Area left clean and safe: YES

Permit Cancels at: 11:45 AM

Authorised Person (Receiver): J. Smith [Signature] Time: 11:45 AM