Whsmp · OPW16/0021

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


Entry Authorisation (Work Coordinator in Direct Control):
The procedures, control measures and precautions appropriate for the safe entry &/or execution of work in this confined
space have been implemented and the persons required to enter/work in the confined space are trained/competent in
accordance with AS 2865 and have been advised of and understand the requirements of the Risk Assessment & Entry
Permit.
Name:                                         Signature:                                   Date:              Time:

Constraints:      This Entry Authorisation is valid until the following occurs, or the date and time shown:
                                                                                           Date:              Time:
Personnel Entry
I the undersigned hereby acknowledge that I understand the procedures, control measures and precautions to be
observed with the entry &/or work and exit involved with this confined space. I will endeavour to comply with these
requirements at all times and report any new/unforeseen hazard that presents a risk to safety.
Sign on                                                                        Sign Off
Print Name (First & Last)   Date          Time         Signature               Date        Time           Signature




Withdrawal of Entry Authorisation (Work Coordinator in Direct Control):
All persons and equipment have been accounted for and the equipment and confined space have been restored
correctly and safely.
Name:                                         Signature:                                   Date:              Time: