Permit to confined_space_work نموذج تصريح دخول الأماكن المغلقة - المحصورة - الضيقة عربي انجليزي

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%