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Confined Space Entry Permit ACC Jamul

This confined space entry permit outlines the details, physical risks, and safety controls for work taking place in a confined space. It lists potential risks like oxygen deficiency, toxic gases, flammable substances, and extreme temperatures. It requires attaching a risk assessment and rescue plan. A standby person must be named and gas testing provided by an authorized tester. The technical supervisor and safety coordinator must review and recommend proceeding. Upon work completion, the performer and supervisor must verify all tools and equipment were left safely. The permit can be cancelled if safety controls are not implemented.

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100 views1 page

Confined Space Entry Permit ACC Jamul

This confined space entry permit outlines the details, physical risks, and safety controls for work taking place in a confined space. It lists potential risks like oxygen deficiency, toxic gases, flammable substances, and extreme temperatures. It requires attaching a risk assessment and rescue plan. A standby person must be named and gas testing provided by an authorized tester. The technical supervisor and safety coordinator must review and recommend proceeding. Upon work completion, the performer and supervisor must verify all tools and equipment were left safely. The permit can be cancelled if safety controls are not implemented.

Uploaded by

athulpcucek
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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CONFINED SPACE ENTRY PERMIT № CSP0001

Note : This Permit valid maximum 7 (seven) days.

I. Details II. Physical Risks and checklist of Controls

Task description:________________________________________ Oxygen deficiency


Presence of toxic gas, fume or vapor
Location of work:________________________________________ Presence flammable substances and oxygen enrichment
Attachment to GWP no.____________ The ingress of solid and liquid materials
Extreme temperature
Slips, trips and fall
Requested by:__________________________________________ Electrocution if working in incased metal structure
Name of Contractor/ Performer
III. Complete the safety control checklist prior to entry
Is the Risk Assessment attached to the permit? Yes/ NO (write N/A if not applicable)

Is the Rescue Plan & Measures attached to the permit? Yes / No

Name of Standby person________________________________


Prepared by:

_____________________________________________________
Contractor/Performer (Name/ /Signature/Date)
Gas test is provided by:

____________________________________________________
ACC Authorized Gas Tester (Name/Signature/Date)
Reviewed by:

_____________________________________________________
ACC Technical Supervisor (Name/Signature/Date)
Recommending to proceed:

____________________________________________________
ACC OHS Coordinator (Name/Signature//Date)
Permitted to Proceed by:

____________________________________________________
ACC Line Manager (HOD) /Name/Signature/Date

IV. Work completion & turn over:


1. The work for which this Permit was issued has been
properly performed;
2. All tools, equipment, and electrical apparatus affected by
the work have been left in a safe, clean condition.

Turned over by: ___________________________


Performer
Checked & verified by:
I commit to Implement and monitor the above safety controls and
____________________________________________
conditions on site until the job is completed. I understand that
ACC Technical Supervisor
failure to implement will be grounds for cancellation of this permit
___________________________________________
by: ACC Safety Coordinator

Accepted by: _____________________________________


_______________________________________
Performer’s Name/ /Signature/ Date
ACC Line Manager( HOD)

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