NSRP Project: Confined Space Entry Certificate
NSRP Project: Confined Space Entry Certificate
NSRP Project: Confined Space Entry Certificate
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
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)
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
Satisfactory ACCESS & EGRESS Fire blanket Full Body Harness / Lifeline
Gas test requirement, Check if continuous Gas test Wet down internals Chemical Suit / Gloves / Boots
PERMIT ISSUER
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)
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: