Confined Space Entry Permit

1. Permit Details

Permit Number: [CS-2023-001] Date of Issue: [DD/MM/YYYY] Time of Issue: [00:00 AM/PM] Valid Until: [DD/MM/YYYY] [00:00 AM/PM]

2. Location and Description of Work

Company Name: [Your Business Name] Site Address: [Street Address, Suburb, State, Postcode]

Description of Confined Space: [e.g. Stormwater pit, Wine tank, Sewer main]

Specific Location: [e.g. Rear of Block B, near Loading Dock]

Work to be Done: [Briefly describe the task, e.g. Cleaning sludge, Welding bracket, Inspecting valves]

3. Hazard Identification

Potential Hazards (Check all that apply):

• Oxygen deficiency or enrichment
• Flammable atmosphere
• Toxic gases or vapours
• Engulfment (liquid or solid)
• Mechanical / Electrical hazards
• Noise / Vibration
• Temperature extremes
• Biological hazards
• Other: [Specify]

4. Risk Control Measures

Atmosphere Testing (Results MUST be recorded before entry):

• Oxygen: [%] (Safe range 19.5% - 23.5%)
• Flammable Gas: [% LEL] (Safe range 0% - 10% LEL)
• Toxic Gas: [ppm] (e.g. H2S, CO)
• Time of Test: [00:00 AM/PM]
• Test Equipment Serial No: [Serial Number]

Isolation / Lock Out Tag Out (LOTO):

• Electrical isolation (Lock/Tag applied)
• Mechanical isolation (Lock/Tag applied)
• Pipe isolation (Blind/Blank installed)
• Other isolation: [Describe]

Ventilation:

• Natural ventilation
• Mechanical ventilation (Extraction/Supply)

Personal Protective Equipment (PPE) Required:

• Safety Helmet
• Safety Boots
• High Visibility Clothing
• Safety Glasses / Goggles
• Hearing Protection
• Respiratory Protection (Type: [Specify])
• Harness (Fall Arrest)
• Lifeline attached
• Gloves (Type: [Specify])
• Other: [Specify]

5. Entry Personnel

Authorised Entrants (Names & Signatures):

Name	ID No.	Time In	Time Out	Signature
[Name]	[ID]	[Time]	[Time]	[Sign]
[Name]	[ID]	[Time]	[Time]	[Sign]
[Name]	[ID]	[Time]	[Time]	[Sign]

Standby Person:

• Name: [Full Name]
• Location: [Exact location outside space]
• Communication Method: [e.g. Two-way radio, Hand signals, Tug line]
• Emergency Contact Number: [000 or Site Emergency #]

6. Emergency Procedures

Emergency Rescue Plan Attached: [ ] Yes [ ] No

Rescue Equipment Available (Check all that apply):

• Tripod and winch
• Full body harness
• Lifelines
• Breathing apparatus (SCBA)
• First aid kit
• Fire extinguisher

7. Acknowledgement and Sign-off

I acknowledge that I have read and understood the contents of this permit and the associated risk assessment. I agree to comply with all safety controls listed.

Authorised Entrant Signatures:

1. ---

2. ---

3. ---

Issuer Declaration: I confirm that all necessary isolations have been made, atmosphere is safe, and control measures are in place.

Issuer Name: [Full Name] Position: [Job Title] Signature: __________________________

Cancellation / Extension: This permit is cancelled at: [Time] on [Date] Reason: [e.g. Work completed, Atmosphere changed, Shift ended]

Cancelled By: [Name] [Signature]