Confined Space Entry Permit

Permit ID

All contractors, tenants and ADG staff must complete this Permit and have it approved before commencing any confined space entry work. The purpose of this Permit is to ensure that all safety aspects of confined space entry work have been considered and actioned.

Status

Are you or your business registered with ADG? *

YesNo

Note: registration is necessary before any work on ADG Leased Area is permitted.

*Please register your business with ADG before proceeding. Please click here to register.

Have you completed the Working on Airport induction? *

YesNo

*Please complete the Working on Airport induction before proceeding with the application.

Part 1 – Application Details

Assessor *

Select Airport *

Applicant Name *Person in Charge of Works

Phone number *

Business Name *

ABN Number *

Email *Applicant's email address

ADG Point of Contact/ Project Manager Details

ADG Point of Contact Name *

ADG Point of Contact Phone Number *

ADG Project Manager Email *

Other PM Email *

Part 2 – Description of Works

Address of Works *

Pit Number

Start Date of Works *

End Date of Works *

*End date of works should be after the start date of works.

Hours of Work (From) *

Hours of Work (To) *

Describe the planned works *

Start and End Date of Works validation

Part 3 – Isolation

Does the space need to be isolated from:

Water, gas, steam or chemicals? *

Yes No

Comments (Isolation location & method) *

Auto fire extinguishing systems? *

YesNo

Comments (Isolation location & method) *

Hydraulic or electric power? *

YesNo

Comments (Isolation location & method) *

Sludge, deposits or wastes? *

YesNo

Comments (Isolation location & method) *

Are Locks and/or tags affixed to isolation points? *

YesNo

Comment *Note: The Conditions of Isolation from points of supply must remain unchanged during the currency of this Permit.

Part 4 - Atmosphere

The atmosphere in the confined space has been tested and the results are as follows:

Note: LEL = Lower Explosive Limit, CSE = Confined Space Entry

Oxygen *in %

Other gasesin ppm

Other gases (if any)in ppm

Flammable gases in % LEL

Flammable gases (if any)in % LEL

Other airborne contaminants

Will entry be made:

Without respiratory protection? *

NoYes

With supplied air breathing apparatus? (Must be approved by the H&S Manager) *

NoYes, only CSE trained

With Emergency Egress System? (Must be approved by H&S Manager) *

NoYes, Only CSE trained

*If safe levels are exceeded, no entry is allowed. Contact the Health & Safety Manager.

Part 5 – Hot Work

Are all areas clear of combustibles, including atmosphere? *

NoYes

Is there suitable access and a designated exit? *

NoYes

Has the Safe Work Method Statement for hot work been approved and attached? *

NoYes

List the prevention equipment available:

Part 6 – Personal Protective Equipment and Safety Precautions

Others (if any)

Indicate what other safety precautions will be taken:

YesNo

Warning notices posted near the site and barricades set up

YesNo

Confined space entry training provided to everyone on site prior to the start of works

YesNo

The air monitored continuously

YesNo

Part 7 – Acknowledgement of Applicant

I confirm that:

I will comply with the ADG special conditions decided by the ADG authorised person.
I agree to repair any damage caused to the site or pay the costs associated with any repair work.
I agree to comply with all work health and safety requirements as outlined in our SWMS.
I will return my copy of this Permit for cancellation by the ADG Authorised Person, once work has been safely completed.

Name of Applicant *

Signature *

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Applicant's Signature Date

Part 8 – ADG Special Conditions

Please upload relevant documents (if any)

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Part 9 – Authorisation to Work

Is the permit approved? *

YesNoMore Information Required

Notes to the applicant *

I authorise the works listed above to proceed during the specified dates and times, in accordance with the ADG special conditions noted in Part 8 above: *

Name and Title of ADG Authorised Person *

Phone Number *

Authorised Person's Signature *

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Date and Time ADG Authorised Person

Part 10 – Cancellation of Permit from the Applicant

Cancellation Date and Time *

As-built drawings or amendments are: *

Not requiredRequired

As-built drawings or amendments will be provided by *Responsible Person

Provided by date *For providing As-built or amendments drawings

Please attach a photo of the site. *

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I confirm that: *

The works described in this Permit have been satisfactorily completed or stopped and made safe.

All people under my control have been removed from the site. *

Any outstanding matters have been forwarded on for action. *

This Permit is now cancelled.

Name of Person in Charge of Works *

Signature (Person in Charge of Works) *

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Person in Charge of Works Signature Date

Part 11 - Cancellation of Permit from ADG

Name of ADG Authorised Person *

Signature *

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Date *

CAPTCHA *

*Please fix the date above

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