Enclosed Space Entry Permit

This permit relates to entry into any enclosed space as described in Chapter 3 Ship's Name Identification of Enclosed Space Reason for Entry ^ This permit is valid from (time) (date) to (time) (date)

Pre-Entry Preparations (To be completed by the master or responsible officer) 1.1. Has the space been isolated to prevent inadvertent contamination? 2.2. Has the space been cleaned where necessary? 3.3. Has the space been thoroughly ventilated? 4.4. Do pre-entry atmosphere tests meet required levels? Oxygen - 21% by volume ________________Hydrocarbon - Less than 1 % of LFL________ Toxic Gases___________ ppm (specify gas & TLV) ________________________________ 5.5. Will frequent atmosphere checks be made while the space is occupied? 6.6. Will the space be continuously ventilated during the period of entry and during work breaks? 7.7. Is adequate illumination provided? 8.8. Is rescue and resuscitation equipment prepared and ready for immediate use? 9.9. Will a trained person be in constant attendance at the entrance to the space? 10.10. Is the Officer of the Watch (bridge, engine room, or cargo control room) aware of the planned entry? 11.11. Has a means of communication between persons entering the space and those at the entrance been agreed and tested? 12.12. Are emergency and evacuation procedures established and understood? 13.13. Is there a system for recording who is in the space? 14.14. Have all persons entering the space been trained in enclosed space entry procedures, and in safety and emergency procedures? 15.15. Is the space marked as safe for entry? ENCLOSED SPACE ENTRY PERMITTED Signature of master or responsible officer Date Signature of responsible person supervising entry Time Date Time

THIS PERMIT BECOMES INVALID IF VENTILATION OF THE SPACE IS INTERRUPTED OR IF ANY OF THE CONDITIONS NOTED IN THE CHECKLIST CHANGE