Confined Space Authorization

Safety Requirements

Has the equipment been?

Isolated from power/steam/air(Required)
Isolated from liquid or gases(Required)
Depressurized or drained(Required)
Blanked/blinded/disconnected(Required)
Flushed/purged(Required)
Man ways open & ventilated(Required)
Adequately cooled(Required)
Name of confined space attendant(Required)
Radiation sources removed(Required)
Proper lighting provided(Required)

Expected Residual Hazards

Lack of O2(Required)
Heat/Steam(Required)
Combustible/Liquid(Required)
Electricity / Static(Required)
H2S / Toxic Gases(Required)
High Humidity , High Temp(Required)

c) Protection Measures

Gloves(Required)
Protective Clothing(Required)
Grounded air ejector / blower / AC(Required)
Max Men Allowed at a time(Required)
Ear Plug / muff(Required)
Dust / Face Mask(Required)
Safety harness / lifeline(Required)
Any other(Required)
Attendant with SCBA(Required)
Communication Equipment(Required)

Gas Test

Type(Required)
MM slash DD slash YYYY
Time(Required)
:

Authorization/Renewal

MM slash DD slash YYYY
Time From(Required)
:
Time To(Required)
:
Add more

Permit Closure

Work(Required)
Site Handed Over in Good Condition(Required)
Housekeeping Done(Required)
Multi Lock Removed(Required)
MM slash DD slash YYYY
Time(Required)
:
Agree to above site was checked and found safe(Required)
MM slash DD slash YYYY
Time(Required)
:
Site was checked and found safe(Required)