Annex II of NR-33 – Entry Permit

(MTP Ordinance No. 1690, of June 15, 2022)

Informative model for preparing confined space entry permit

Organization Name:

Confined Space Location:

Confined Space No.:

Issuance Date and Time:

Completion Date and Time:

Work to be performed:

Authorized Workers:

Attendant:

Rescue Team:

Entry Supervisor:

Procedures to be completed before entry

  1. Isolation Yes ( ) No ( )
  2. Initial atmosphere test: time

Oxygen_________________________________________________ % O2

Flammables_______________________________________________ % LEL

Toxic gases/vapors _____________________________________ ppm

Toxic gases/vapors (list monitored gases in the entry permit adapted to the gas detector instrument) ____________________________________________ppm

Toxic dusts/fumes/mists ______________________________ mg/m³

Legible name/signature of Test Supervisor:

  1. Lockout, Tagging, and Isolation N/A ( ) Yes ( ) No ( )
  2. Purging and/or washing N/A ( ) Yes ( ) No ( )
  3. Ventilation/exhaust – type, equipment, and time N/A ( ) Yes ( ) No ( )
  4. Test after ventilation and isolation: time :

Oxygen _________________________________________________ % O2 > 19.5% or < 23.0%

Flammables _______________________________________________ % LEL < 10%

Toxic gases/vapors (list monitored gases in the PET adapted to the gas detector instrument) ppm

Toxic dusts/fumes/mists ________________________________________ mg/m³

Legible name/signature of Test Supervisor:

  1. General lighting N/A ( ) Yes ( ) No ( )
  2. Communication procedures N/A ( ) Yes ( ) No ( )
  3. Rescue procedures N/A ( ) Yes ( ) No ( )
  4. Procedures and protection for vertical movement N/A ( ) Yes ( ) No ( )
  5. Training for all workers? Yes ( ) No ( )

Are they valid? Yes ( ) No ( )

  1. Equipment:
  2. Continuous gas monitoring equipment suitable for work in potentially explosive areas with direct reading and alarms in conditions: Yes ( ) No ( )

Lanterns Yes ( ) No ( )

Protective clothing Yes ( ) No ( )

Fire extinguishers Yes ( ) No ( )

Helmets, boots, gloves Yes ( ) No ( )

Respiratory protection equipment/self-contained or airline system with escape cylinder Yes ( ) No ( )

Safety harness and lifelines for authorized workers Yes ( ) No ( )

Safety harness and lifelines for the rescue team Yes ( ) No ( )

Ladder Yes ( ) No ( )

Vertical movement equipment/external supports Yes ( ) No ( )

Electronic communication equipment suitable for work in potentially explosive areas Yes ( ) No ( )

Self-contained or airline system with escape cylinder for the rescue team Yes ( ) No ( )

Electrical and electronic equipment suitable for work in potentially explosive areas Yes ( ) No ( )

Procedures to be completed during work

  1. Hot work permit Yes ( ) No ( )

Emergency and Rescue Procedures:

Phones and contacts:

Ambulance: ________ Firefighters:________ Security: ______

ATTENTION:

Entry must be prohibited if any field is not filled in or contains a “no” mark.

The lack of continuous atmospheric monitoring inside the confined space, alarm, attendant’s order, or any safety risk situation for workers implies immediate area abandonment.

Any team exit implies issuing a new entry and work permit, except when the entry permit is extended, meeting the requirements of item 33.5.12.1 of this NR.

This entry permit must be available at the work site until its closure.

After the work, this permit must be archived.