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1. Checklist
Yes No
a. The work location is isolated from all sources of danger
d. The atmosphere has been tested and is free from toxic and
flammable substances
Name of Worker(s) :
2. Reading
Time Checked
Item
O2(%)
H2S (ppm)
CO(ppm)
LEL (%)
Applicant Authorised Gas Tester (AGT) ESH Personnel
Applied by Approved by
Acknowledge by The work has not been completed and The work has been completed and all
permission to continue is hereby requested personnel under my supervision,
Signature: (up to 4 hours maximum) material and equipmet have been
withdrawn.
Name: Permit is extended to:
IC No: Signature:
Signature:
Name: Name:
Date: Date: