THE PROVISION OF PIPELINE INSTALLATION

SERVICES

SMG1 FLOWLINE PROJECT

CONFINED SPACE ENTRY PERMIT

Document N° : Contract N° : Page 1 sur 2
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CONFINED SPACE ENTRY PERMIT

Permit No.
Details of Work:

Work Location:

Description of Hazards:

Expected Work Period: From hrs. To hrs. Date:

Other Permit Required:

Task Supervisor Name: Signature:

No. of Workers:
Action to be taken

Safety Checks Y: Yes N: No N / A : Not Applicable

Item Y/N Y/N Remarks
No hazardous substances present inside vessel
Isolated/blinded from system process, utility, elec.
No combustible material inside
Natural/forced ventilation provided
Breathing apparatus being used specify type
Explosion proof electrics furnished If necessary
Adequate lighting provided Flame proof low voltage
Look out for rescue staff standing by outside confined space Tally board present

Workers to work in pairs (Buddy System)

Lifeline to be furnished safety harnesses to be worn
Standby rescue equipment
Workers received safety training
Other necessary precautions:
Communication with work party inside To raise alarm
Communication to raise alarm in HSE department

Atmospheric Measuring Result:

O2 Content Results:
Name Time Content Signature
Before work start
10:00
13:00
15:00
Comments/Remarks:

Flammable Gas Testing Results;

Name Time Content Signature
Before work start
10:00
13:00
15:00
Comments/Remarks

Permit No.:
Validity of the Permit: From hrs. To hrs. Date:
Reviewed by: Name & Title: Signature:
Issued by: Name & Title: Signature:
Received by : Name & Title: Signature:
Revalidation Permit:
Revalidated DATE
TIME
Issuer NAME
SIGNATURE

Permit closure:
Closed by (Receiver) Name: Time closed: Signature:
(Issuer) Name: Time closed: Signature:
Performing authority Issuing Authority Area Authority