BINDU PROJECTS LIMITEDbPL/WP/FORMAT/06ISSUE: 01REVISION: 01

CONFINED SPACE WORK PERMITWork Permit No. (By Issuing Authority): Issue Date:

GENERAL INFORMATIONTO BE COMPLETED BY PERFORMING AUTHORITYName of the contractor / Employee Requesting the Permit

Department: Number of Operatives working under the permit:

Area of Work: Work Equipment:

Description of Work:

Permit Required for the Period: Date From: Date To:Time From: Time To:Stand-by Watchman Name :

Fire Watchman Name:

* Stand-by watchman must record the “In and Out” of personnel from the confined space. NO PERSON SHOULD ENTER THE CONFINED SPACE WITHOUT THE PRESENCE OF THE STAND-BY WATCHMAN1) Has the equipment to been removed from service? (YES - NO - CHECKED)

Depressurized Water flushedDrained Purged with inert gas/steamIsolated or disconnected Ventilated by natural or mechanical means

2) Are sewer, drains, etc. within 15 m of worksite sealed? (YES - NO - CHECKED)Is site clear of combustible materials? Are fire/safety personnel required for stand by?Is fire protection sited? Are special disposal methods required?Are special warning caution signs posted?

3) Is power cable to be disconnected? (YES - NO - CHECKED)4) Is control cable to be disconnected? (YES - NO - CHECKED)5) Is wind direction to be considered? (YES - NO - CHECKED)6) Are warning notices / area restriction required? (YES - NO - CHECKED)

GAS TEST A B C D E

GAS ANALYSES TEST DateTime

COMBUSTIBLETOXIC H2SO2

Sign. Auth. Gas Tester

Is Gas Test to be repeated? (If yes, how often): _____________________________I understand the hazards associated with the work & have taken all necessary precaution/controls as mentioned in the checklist

Signature of the Engineer Signature of the Performing AuthorityTO BE COMPLETED BY ISSUING AUTHORITY

I have verified that the requirements have been complied. This permit is issued and remains valid under the following conditions.

From: _________________To: _______________ Time: _________________To: _______________ Name & Sign of Permitting/Issuing Authority

PERMIT REVALIDATION: From: ___________________ To : ___________________ Signature: _____________________From: ___________________ To : ___________________ Signature: _____________________From: ___________________ To : ___________________ Signature: _____________________

INDIVIDUAL PROTECTION EQUIPMENT (CROSS WITH AN X): None Ear Plugs Gloves Lab Coat Safety Glasses Ear Plugs Coveralls Ear Muffs Goggles Respirator Safety Harness Coveralls

Disposable Cloth Face Shield Hard Hat Shoe Covers Safety Shoes Other

OTHER SAFETY MEASURES (Specify Other):

CLOSE OUT SECTION:The work is completed and working area has been cleared from debris and equipment

Performing Authority

The site has been checked and working area accepted

Permitting/Issuing AuthorityPERMIT CONDITIONS.Permit is valid only for one job. Approval required for the extension.Extension is permitted only twice or till the request is for fresh day. Fresh permit is required for any change in condition.Lock Out/ Tag Out has to be completed before permitting by the authorized personnel for LOTO.

REQUIREMENTS AND ARRANGEMENTS FOR CONFINED SPACE Note: The whole of the remaining detail of this permit must be completed and signed by the authorising person(s) before

work is to proceed.Y N N/A

Oxygen level at least 19.5% and not more than 23.5%. No toxic gases present      Ventilation (exhaust fan/blower) provided      Stand by trained person with breathing apparatus provided      Use of 24V supply only for hand held electrical tools      No DG sets or IC engine inside confined space      No smoking inside confined space      

Checked & Signed

Performing Authority Permitting/Issuing Authority

HSE Approval I have reviewed this permit and work may proceed.

Name & Signature: Date & Time:

CONFINED SPACE ENTRY LOG

Date of Activity : Equipment Location & No. :Supervisor Name :Emergency Contact No. :

Sr. No. Name of Person Time In Time Out

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