Negri Contractors (Vic) Pty Ltd
Document:
ABN 99 006 337 239
Revision Number:
Isolation/ Confined Space Permit to Work (officer pits)
FO-13-2
Project Name:
FO-13-2
Contact #:
Date:
Permit #
1.4
01-12-21
Atmospheric Testing
Permit to Work Information
Only a Negri approved person is permitted to undertake atmospheric testing for a confined space/ void or area or as required by a risk assessment
- All requirements placed on this permit must be applied with at all times. Where any audit of the permit conditions identifies that any requirement is not being applied the
permit is to be withdrawn, closed, work stopped and an incident investigation commenced by the project manager and the Negri QES manager
Equipment #
Calibration Date
Exact details/ location of Space/ void.
General Information
Permit Type
Permit Start Date:
Time Activated
:
Exact Location of works/
Confined Space location
Is this a continuation of an existing PTW
Permit #
Type of Atmospheric monitoring required:
Date
Time: (initial)
Pit#
Test for Substance
PEL
Oxygen
19.5-23.5
The permit issuer must be a Negri person that is deemed competent to identify the hazards and risks associated with the work and is an approved permit issuer. By signing this permit as active the Permit
Issuer is satisfied that any/all of the requirements are in place and/or can be provided
LEL
<10%
Permit Holder
Hydrogen Sulfide
<10ppm
Carbon Monoxide
<35ppm
Negri Permit Approver
Permit Approvers Contact #
Name
Position
Signature
Name
Signature
Company
The Permit holder is any person associated with the works that is to be accountable for ensuring that all requirements under the permit are applied at all times. By signing this permit the permit holder is
acknowledging that they take accountability to ensure that the works will be done in line with the permit and where new risks are identified, cease work
Are there any other permits open for this scope of work? N
Y
If YES – Permit # ________________________ & Type______________________
Prior to Entry
Test –
Time
Pit#
Continuous
Test –
Time
Pit#
Every 2 Hours as a Minimum
Test –
Time
Pit#
Test –
Time
Pit#
Test –
Time
Pit#
Test –
Time
Pit#
After any Evacuation
Test –
Time
Pit#
NOTES:
Volatile Organic Compounds
Permit Description and Special Requirements
Other
Brief description of scope of works including the exact location, any limitations/ restrictions associated with this permit;
Mechanical Extraction/ Ventilation Required
Y
N
Emergency Plan attached to SWMS?
Gas Testers Name
Y
N
Signature
Any signature above by an authorised Gas Tester indicates that the space is safe for entry and the permit is Enacted.
Are there any drawings/ DBYD etc. associated with the works & are they attached to the PTW? Y
N
N/A
Details ISOLATION REQUIREMENTS: - The following isolations must only be done by a Negri assessed and approved competent person. ALL ISOLATIONS MUST HAVE A MINIMUM OR 2 ISOLATION POINTS
NO ISOLATIONS REQUIRED FOR THIS WORKS
Electrical Isolations
Sentry 1 NAME
Confined Space Sentry Assigned?
Relief Sentry’s NAME
By Signing the above the Sentry’s accept that they are trained & competent, and have established a means of communication with Confined Space occupants
(CONTINUE TO NEXT SECTION)
Mechanical Isolation
Other Required Isolations
Electrical Drawing # (attached)
P&ID drawing # (attached)
Gravimetrical/Hydraulic/ Pneumatic/Heat
Convection/Radioactive etc.
All Workers that are assigned to the works must sign onto and off this permit. Where any worker is redeployed from this works to any other activity for a period of greater than 10
minutes, they are required to sign off this permit. A worker is not permitted to be on more than one (1) confined space permit at any one time
Isolation points identified on drawings?
Y
Isolations undertaken (details)
________________________________________
Worker Name
Isolation points identified on E&I drawings? Y
Isolation Officers Yellow Locks installed
Y
Isolation Officers Yellow Locks installed
Y
Only persons that have been assessed as competent to work in a confined space by Negri are permitted to enter a confined space at any time
Worker Signature
Time on
Time off
Sign Out
________________________________________
Two (2) points (min) of isolation identified Y
Two (2) points (min) of isolation identified Y
Or
Or
Lock box used
Lock Box Number __________
Lock box used
________________________________________
Lock Box Number __________
Isolation point 1 –
Isolation point 1 –
Isolation point 2 -
Isolation point 2 -
RED locks issued to workers (where more than 2
isolation points a lock box is to be used) Y
RED locks issued to workers (where more than 2
isolation points a lock box is to be used) Y
Isolation Officers name
_____________________
Isolation Officers name
_____________________
(drawings to be attached to the PTW)
________________________________________
________________________________________
Isolation point 1 –
Isolation point 2 Isolation Officers name
_____________________
Where this permit is to be closed all workers are to sign out indicating that they have removed any isolations and/or been removed from any confined Space as validated by the Sentry
and the isolation Officer: Where locks remain on an isolation the Negri LOTO procedure is to be applied to ensure that locks can be removed and the worker notified/ disciplined.
WHERE ANOTHER SIGN ON SHEET IS REQUIRED, USE FM-13-03 PERMIT SIGN ON SHEET AND ATTACH IT TO THIS PERMIT WIH THE CORRESPONDING PPEMIT #
The Isolation Officer has tested the above isolations for de-energization and by placing their name on the permit indicated that works may commence.
Isolation Officer
Name
Sign
Date
Permit Holder
Name
Sign
Date
Negri Permit Approver
Name
Sign
Date
PERMIT SIGN OFF AND CLOSURE (PERMIT APPROVER MUST BE THE LAST SIGNATURE ON THIS CLOSE OUT SECTION)
ANY SIGNATURE BELOW THIS LINE INDICATES THAT THIS PERMIT IS CLOSED AND IS NOT TO BE WORKED UNDER. WHERE WORKS ARE REQUIRED A NEW PERMIT IS TO BE DRAWN UP
Name
Sign
Date
Time
Isolation Officer (locks
removed)
Name
Sign
Date
Time
Permit Holder
Negri Permit Approver
Name
Sign
Date
Time
Permit # (attach to the rear of the permit)
Test for Substance
PEL
Oxygen
19.5-23.5
LEL
<10%
Hydrogen Sulfide
<10ppm
Carbon Monoxide
<35ppm
Date
Time: (initial)
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
NOTES:
Date
Time: (initial)
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
NOTES:
Date
Time: (initial)
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
NOTES:
Date
Time: (initial)
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
Test – Time
Pit#
NOTES:
Volatile Organic Compounds
Other
Test for Substance
PEL
Oxygen
19.5-23.5
LEL
<10%
Hydrogen Sulfide
<10ppm
Carbon Monoxide
<35ppm
Volatile Organic Compounds
Other
Test for Substance
PEL
Oxygen
19.5-23.5
LEL
<10%
Hydrogen Sulfide
<10ppm
Carbon Monoxide
<35ppm
Volatile Organic Compounds
Other
Test for Substance
PEL
Oxygen
19.5-23.5
LEL
<10%
Hydrogen Sulfide
<10ppm
Carbon Monoxide
<35ppm
Volatile Organic Compounds
Other