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CSP

GEO WORKS SDN BHD


CONFINED SPACE WORK PERMIT
Sdn

Project : Job No: Date:

Sub Contractor : Duration :


Location : Type of Operation :

1. Checklist
Yes No
a. The work location is isolated from all sources of danger

b. The work location has been drained / vented

c. Dangerous sludge and other deposits have been removed

d. The atmosphere has been tested and is free from toxic and
flammable substances

e. There is an adequate supply of fresh air to the work location

f. Additional permit for Hot Work / Cold Work should be


released if required
(Ref. No : )

g. Appropriate Personal Protective Equipment shall be worn

Name of Worker(s) :

2. Reading

Time Checked
Item
O2(%)
H2S (ppm)
CO(ppm)
LEL (%)
Applicant Authorised Gas Tester (AGT) ESH Personnel
Applied by Approved by

Signature: Signature: Signature:

Name: Name: Name:


IC No: IC No: IC No:

Person In Charge Extension of Work Completion of Permit

Acknowledge by The work has not been completed and The work has been completed and all
permission to continue is hereby requested personnel under my supervision,
Signature: (up to 4 hours maximum) material and equipmet have been
withdrawn.
Name: Permit is extended to:
IC No: Signature:
Signature:
Name: Name:
Date: Date:

Revision No: 01 Issue No: 01 Effective Date: 30/10/2017

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