Bp Anz Confined Space Entry Permit Page 2
Download a blank fillable Bp Anz Confined Space Entry Permit in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Bp Anz Confined Space Entry Permit with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3BPD020205 12/15 W485692
BP ANZ
NOTE: This permit does not authorise any work to be
carried out. A seperate work permit must be issued.
CONFINED SPACE ENTRY PERMIT
Permit Set:
Issued to:
Company:
Recipient:
Location:
TRA No:
Description of confined space:
Gas test certificate no.:
Repeat tests how often:
SAFETY CHECKLIST (State in column YES, NO or NA. All lines must be filled in.)
DETAILS
DETAILS
CHECK
Y/N/NA
BELOW
CHECK
Y/N/NA
BELOW
O.
Has a safety induction been done?
4. Fire protection checked/ in place? List.
NA
NA
A.
Have plant and equipment been thoroughly:
5. Warning notices, locks and tags been fixed to
NA
means of isolation?
1. Depressurised
NA
2. Drained and checked for leakage
6. Fully equipped rescue team on standby?
NA
NA
3. Isolated
-
By Blanking
7 . Lifting gear & harness in position?
NA
NA
-
By Disconnection
NA
8. Emergency communication agreed & standby
NA
personnel instructed?
4. Steamed
NA
5. Water Flushed
9. Persons entering are trained for entry & in use
NA
NA
of respiratory equipment?
6. Ventilated
-
Natural
NA
-
Mechanical
10. C.S. Entry record board at entrance?
NA
NA
B.
1. Are sewers, pits & drains and contaminated
NA
NA
C. Is access and exit provided?
ground within 15m of worksite rendered safe?
2. Combustible material removed & leaks
NA
NA
D. “Lead” precautions necessary/taken?
controlled? Product movement stopped?
3. Air contamination sources identified and
E. Electrical equipment been isolated
NA
NA
controlled?
and tagged?
PERSONAL PROTECTION REQUIRED (Tick where relevant.)
Eyes
Ears
Hands
Feet
Breathing
Body - Other
Goggles
Ear Protection
PVC Gloves
Safety Shoes
Canister Mask
Safety Harness
Overalls
Shield
Gloves
Rubber Safety Boots
Air Supplied Respirator
PVC Suit
Hard Hat
Safety Glasses
Gauntlets
Other, Specify:
SPECIAL INSTRUCTIONS:
This permit to be read in conjuction with work permit
ELECTRICAL ISOLATION BY:
APPROVED BY:
RE-ENDORSEMENT OF PERMIT TO BE BY:
DAILY/HOURLY
AUTHORISATION TO CARRY OUT WORK
I certify that the above equipment/site is safe for entry by nominated persons subject to the specified requirements:
Issued by: Name:
Tel No.
Signature:
Countersigned by: Name:
Signature:
/
/
/
/
Permit Valid From Date
am/pm
To Date
am/pm
I understand the nature of the work and certify that the above conditions will be observed at all times and received by:
/
/
Contractor/Employee: Name:
Signature:
WORK COMPLETED
/
/
Contract/Employee:
Signature:
Date:
am/pm
WORK HAND BACK
/
/
Site Representative:
Signature:
Date:
am/pm
FOR PERMIT ISSUE AND DISPLAY SEE REVERSE OF THIS FORM
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal