This document is a permit for confined space work. It provides information such as the work location, job description, dates and times of validity for the permit, and a checklist of safety items that must be checked and addressed before work can begin. The checklist includes requirements like ventilation, isolation of machines, acceptable gas readings, use of safety equipment, and having standby personnel on site. Authorized signatures are needed to issue the permit after inspection and to terminate it after work is completed or stopped due to a safety violation.

1. Tamer Sharaki For Training & Consultancy
TSTC
www.tstc.com.eg
Permit to Confined Space work
‫المحصورة‬ ‫األماكن‬ ‫فى‬ ‫العمل‬ ‫تصريح‬
Permit for: Confined space ‫تصريح‬‫دخول‬‫تـنكات‬/‫مكان‬‫محدود‬ Sr. No. Permit No.
Date:
Validity period: FROM:_____Hours on Date:_________ UNTIL:_____Hours on Date:__________
Work location:
Job description:
I declare that it is safe and human worthy for carrying out the work in this enclosed space.
Name of Gas inspector: Signature: Time: Date:
The following items must be checked and the area made safe for the job prior to issuing the
permit
Item Done N/A Item Done N/A
Safety Toolbox Briefing talk conducted Metal / Rope Ladders
‫ساللم‬‫معدنية‬/‫حبال‬
Depressurised &/or Drained ‫تم‬‫التفريغ‬/‫التصفية‬ Lifting Basket‫سلة‬‫انزال‬‫لالفراد‬
Steamed &/or Water Flushed ‫تم‬‫الغسيل‬‫بالبخار‬/‫بالماء‬ Goggles ‫نظارات‬‫سالمة‬
Ventilated by natural draft properly ‫تمت‬‫التهوية‬‫الطبيعية‬
‫الكافية‬
PVC Gloves ‫قفازات‬‫مطاطية‬
Isolated by Blinding/Disconnecting ‫تم‬‫العزل‬‫بواسطة‬
‫السد‬/‫الفصل‬
B.A.Sets ‫اجهزة‬‫تنفس‬‫نقالة‬
Machines & Devices inside isolated & tagged
‫تم‬‫عزل‬‫االالت‬‫و‬‫االجهزة‬‫بالداخل‬‫و‬‫وضعت‬‫البطاقات‬
Face Visors ‫اقنعة‬‫حماية‬‫الوجهة‬
Temp. Humidity. Air Velocity within Safe Limits
‫الحرارة‬-‫الرطوبة‬-‫سرعة‬‫الهواءفي‬‫الحدود‬‫االمنة‬
Air Supplied Masks ‫اجهزة‬
‫تنفس‬‫بالهواء‬
Air Blower to be kept Running for Ventilation ‫تلزم‬
‫التهوية‬‫بتشغيل‬‫مروحة‬‫باستمرار‬
Chemical Resistant Clothing
‫مالبس‬‫مضادة‬‫للكيماويات‬
Process & Maint. Stand by Personnel on Site ‫تم‬‫توفير‬
‫اشخاص‬‫من‬‫التشغيل‬‫و‬‫الصيانة‬‫بالموقع‬
Safety Harness & Lifelines
‫احزمة‬‫سالمة‬‫و‬‫حبال‬‫انقاذ‬
Repeated / Continous Gas Monitoring needed ‫يلزم‬
‫اجراء‬‫اختبارات‬‫غازات‬‫دوري‬‫مستمر‬‫ة‬ /
Radio Sets ‫اجهزة‬‫اتصال‬
Lifting Machine Tested on Recommended time ‫تم‬
‫اختبار‬‫الة‬‫الرفع‬‫في‬‫الموعد‬‫المقرر‬
Lighting Lines > 50 V ‫خطوط‬
‫اضاءة‬‫اقل‬‫من‬50‫فولت‬
Area Clean & Safe ‫المنطقة‬‫نظيفة‬‫و‬‫امنة‬ Other Safety Require or Action:
Name / ID of Watchman
Name / ID of: Supervisor
Name / ID of the appointed Safety Inspector for this section of the structure:
I am satisfied that it safe to carry out the work described above and the permit is issued. I Certify that I have
inspected the Site and it is Safe for Entry Work to Start
Name of authorizing
authority:
Signature: Time: Date:
The work is completed / stopped due to a safety violation / and the permit is terminated.
Name of job /
inspection authority
Signature: Time: Date:
Signe In/Out Sheet to be located in job location with Gas Test Records ‫الغاز‬ ‫إختبار‬
Gases
‫الغازات‬
Acceptable Readings
‫المقبوله‬ ‫القراءات‬
Actual Readings
‫الفعليه‬ ‫القراءات‬
Signed by Competent Person, Gas Testing ‫إختبار‬ , ‫المؤهل‬ ‫الشخص‬ ‫طريق‬ ‫عن‬ ‫موقعه‬
‫الغاز‬
Toxic
‫سامه‬
Zero‫صفر‬
Flammable
‫لإلشتعال‬ ‫قابله‬
Zero ‫صفر‬
Oxygen
‫األكسجين‬
Between 19.5%
and 21%
‫بين‬19.5%‫و‬21%