JOC: 0916 927 189

Attached to PTW No:

 METHOD STATEMENT  JSA  PLOT PLAN / DRAWING SLD/P&ID ISOLATION CERTIFICATE SAFETY DATA SHEET

From : To:
Planned Work Date
TO BE COMPLETED BY PERMIT RECEIVER

Company: Work Location: No. of Workers:

Equipment No. / Vessel No. :

Scope of Work / Purpose of Entry:

Tools & Equipment to be used.:

Task Supervisor's Name: Badge Number: Contact Number:

No work shall commence in Confined Space without a "Stand by Man" in placed. The "Stand by Man" shall be trained and shall not do any other work than monitoring
the risks at Confined space area and communicate with others inside the confined space.
Stand by Man Name: Badge Number: Contact Number:

The confined space may only be entered after initial gas monitoring test have been completed and the prescribed safety requirements are in placed.
INITIAL GAS TEST (JGCS)

GAS TEST Result Date Time AGT Name Signature

H2S ( < 10 ppm )

O2 ( 19.5-23.5% )

CO2 (%)

LEL ( 0% )
SAFETY REQUIREMENTS
Preparation Fire and Gas Precautions PPE / SAFETY EQUIPMENTS
Isolations required? (Isolation Certificate to be attached) No Smoking SCABA

Work Procedures & Task Risk Assessement Fire Extinguisher Other respiratory equipment,specify below

Rescue Plan/Equipment/Trained rescue team available (Capacity:________ Type:________ Qty:________ ) _________________________________

Satisfactory ACCESS & EGRESS Fire blanket Full Body Harness / Lifeline

Purging / Flushing / Inerting required Charged Fire Hose Mechanical Ventilation

Gas test requirement, Check if continuous Gas test Wet down internals Chemical Suit / Gloves / Boots
PERMIT ISSUER

Ventilation -- Natural Mechanical Intrinsically safe equipments Disposable Coveralls

Means of communication at all times Combustibles removed Lighting (Safe Voltage)

Identify: ___________________________ Non spark tools

Compressed gas cylinders located at safe distance from Hot work not permitted within ___________ meters Eye & Face Protection
entry points. from source. Hearing Protection

All Supervisors and Workers received CSE Training Others: (specify below)

Warning Signs & Emergency Number to be posted on site

I ACKNOWLEDGED THAT ALL PREPARATION WORKS AND SAFETY REQUIREMENTS ARE IN PLACE AND THAT THE WORK IS SAFE TO PROCEED
JGCS Area Supervisor / Engineer: Contact Number: Date:

From : To:
Permit Validity

I ACKNOWLEDGE THE RECEIPT OF THIS CERTIFICATE AND UNDERSTAND FULLY THE CONDITIONS AND PRECAUTIONS REQUIRED.
ACCEPTANCE

I WILL ENSURE THAT ALL PERSONNEL UNDER MY AUTHORITY UNDERSTAND THESE REQUIREMENTS.
Task Supervisor /Permit Receiver Name: Contact Number: Date: