Whsmp · OPW16/0021

                                                                                Confined Space Entry Permit
                                                                                                                HB-HSEQ-F-075
                                                                                                                    Version: 2


Personal Protective Equipment (PPE) Requirements & Other Precautions
Minimum PPE / other items
                                     Yes    No   Provide Clarifying Details as Required:
required:
Supplied air breathing apparatus
Air purifying respirator
Particulate mask
Safety harness and lanyard / lifeline
Head protection
Face shield / goggles / safety glasses
Ear muffs / plugs
Gloves
Warning notices / barricades required
Specific lighting provisions required
Specific hot work controls required
Other:
Attachments (other documents/plans
prepared)
Permit Request:
This acknowledgement signifies a formal request to commence confined space entry / works. As the person requesting
this permit, I hereby certify that:
  I am competent to coordinate this confined space entry / work in accordance with the Risk Assessment & Entry
     Permit details;
  I shall undertake to implement all planned and necessary controls to ensure safe entry / work; and
  I shall monitor confined space hazards and control methods throughout the entry / work.
Name:                                         Signature:                                 Date:                Time:
Hutchinson Builders Authorisation:
This Hutchinson Builders Authorisation signifies that the planning component of the Risk Assessment & Entry Permit has
been completed and that confined space entry / work is authorised to commence in accordance with the Permit
Request.
Name:                                         Signature:                                 Date:                Time:

Section 3 – Implementation
Atmospheric Testing / Monitoring Guide:
Atmospheric Issue Safe Level                        Caution (Entry during Emergency Response / With Additional Controls
                                                    Only)
Oxygen             > 19.5 % and up to 23.5%         < 19.5% need positive pressure supplied air breathing apparatus.
Contaminants:
CO                 < 30 ppm                         Generally, positive pressure supplied air breathing apparatus may be
H2S                < 10 ppm                         worn at levels approaching and slightly over the exposure standard
CO2                < 5000 ppm                       as determined as part of Risk Assessment and control measure
NH3                < 25 ppm                         implementation.
Other              As per specific exposure
                   standards
LEL                < 5%                              > 5% and up to 10 %
                                                     Entry permitted in emergency response. However, if during work the
                                                     level rises to above 5% and up to 10%, personnel are to evacuate,
                                                     unless a suitably calibrated combustible substance detector is used
                                                     at all times while personnel are in the space.
For other contaminants not listed, specific monitoring devices and pre-work planning will be required to ensure safe entry
                                                            / work.
Atmospheric Test Results:
    When                         Atmospheric Test Results                                      Verification
 Date   Time           O2       CO    H2S      LEL                                Meter         Entry           Name
                                                                                 Number       Permitted
                                                                                              (Yes / No)




The atmosphere in the space is safe to enter:
 Without respiratory protection               With an air purifying device       With a supplied-air device