CONFINED SPACE ENTRY PERMIT

Project Name: Permit No.:

Date: From: To: Duration (Time): From: To:
1. Details of Work:
1.1 Name of Company:
1.2 Location of Work:
1.3 Description of Work:

1.4 Person in Charge (supervisor): No. of Workers:

1.5 Watchman Name:
1.6 Equipment & Tools
to be used:
Fire Hazard Fall From Height Combustible Materials

2. Hazard Dust / Suffocation Flammable Gases Oxygen Deficiency

Considerations
Electrical Hazard Limited Visibility Limited Means of Entry & Exit

Additional Hazards to be present: (for further, you may use back side of this page):

Fire Extinguisher PPE Do Gas testing

3. Precautions &
Fire Protection Full body harness Proper Ventilation Watchman Available

Additional Precautions to be taken: (for further, you may use back side of this page): Check combustible materials
presence, Check Oxygen Level, Caution signs posted, Workers to work in pair, Maintain confined space entry log, Do Toolbox
talk.

4. Atmospheric Test: Gas test required? Yes No If yes record the results below
Name Time Flammable 0% LEL Oxygen 23.5%-19.5% H2S Signature

Remarks Regular basic PPE, availability of adequate supervision, method of statement, & risk assessment, etc., are mandatory.
Person Authorized Permit Name Position Sign Date
Permit Receiver from Sub-Contractor:
Permit Issuer from HEES:
Tick Permit Statement Person Name Sign Date

Permit date is finished, job is still not Request (Receiver)

finished, Please extend the date of Approved (Issuer)
the Permit Permit extended up to:
Request (Receiver)
Permit is closed, job is completed
Approved (Issuer)
Permit Cancellation:
Cancellation Remarks:
Cancellation Requested By: Authorized By:

HEES-PTW-07, REV-00
 CONFINED SPACE ENTRY LOG
Location: Equipment: Date:
AUTHORIZED ENTRANTS
Entrant Name ID# Time Signature
IN OUT IN OUT IN OUT

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Name & Sign of Entry Attendant: Date:

HEES-PTW-07, REV-00