PERMIT TO WORK - CONFINED SPACE

1. General Details

Permit Number: [PERMIT-001] Company Name: [COMPANY NAME] Site Location: [SITE ADDRESS] Date of Issue: [DD/MM/YYYY] Time of Issue: [HH:MM AM/PM] Time of Expiry: [HH:MM AM/PM] (Must not exceed 24 hours)

2. Confined Space Description

Location of Space: [SPECIFIC LOCATION, e.g., North Tank, Pit 4] Type of Space: [e.g., Storage Tank, Sewer, Vessel, Manhole] Purpose of Entry: [e.g., Cleaning, Inspection, Maintenance]

3. Hazard Identification

Identify all hazards present in the space.

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

4. Risk Control Measures

List controls implemented for the hazards above.

Atmospheric Testing:

• Oxygen: [RESULT] % (Safe range 19.5% - 23.5%)
• Flammable Gases: [RESULT] % LFL
• Toxic Gases: [RESULT] ppm
• Test Time: [HH:MM AM/PM]
• Tester Name: [NAME]

Cleaning and Preparation:

• Space drained and purged
• Space cleaned of residues
• Continuous ventilation provided

5. Isolation Procedures (Lock Out Tag Out)

Ensure all energy sources are isolated.

Energy Source	Isolation Point	Lock Applied? (Yes/No)	Tag Applied? (Yes/No)	Initials
Electrical	[LOCATION]	[ ]	[ ]
Mechanical	[LOCATION]	[ ]	[ ]
Pneumatic	[LOCATION]	[ ]	[ ]
Hydraulic	[LOCATION]	[ ]	[ ]
Steam/Water	[LOCATION]	[ ]	[ ]
Other	[LOCATION]	[ ]	[ ]

6. Personnel and Roles

Authorised Person (Issuer): [NAME] [SIGNATURE]

Authorised Entrants:

1. [NAME] [SIGNATURE] Time In: [ ] Time Out: [ ]
2. [NAME] [SIGNATURE] Time In: [ ] Time Out: [ ]
3. [NAME] [SIGNATURE] Time In: [ ] Time Out: [ ]

Standby Person: [NAME] [SIGNATURE] Location of Standby Person: [SPECIFIC LOCATION OUTSIDE SPACE]

7. Emergency Equipment

Ensure the following equipment is available and checked.

• Tripod and winch / retrieval system
• Full body harness (one per entrant)
• Lifelines attached
• Emergency breathing apparatus (SCBA or airline)
• First aid kit
• Fire extinguisher
• Communication equipment (radio/two-way)
• Emergency lighting

8. Rescue Plan

Brief description of rescue procedure: [e.g., Do not enter space. Use tripod winch to retrieve incapacitated person. Call emergency services on 000.]

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: _____________________ Time: ________ Standby Person Signature: ___________________ Time: ________

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10. Permit Closure

Work Completed: [YES / NO] Reason if Incomplete: [TEXT] All personnel accounted for: [YES / NO] All locks and tags removed: [YES / NO] Area left clean and safe: [YES / NO]

Permit Cancels at: [TIME]

Authorised Person (Receiver): [NAME] [SIGNATURE] Time: [HH:MM AM/PM]

THIS PERMITS EXPIRES 24 HOURS AFTER ISSUE TIME. WORK MUST STOP IF PERMITS EXPIRE.