Medium-consistency pump MC
STANDARD, C-01-000000
Rev. 0, 2010.02.09 SAFETY Kap.2 , Seite 20 of 20
GRZ-2698567-v1-Safety.FM
2.19 Permit for work in enclosed / confined spaces
Object / location / point at which work is performed: . . . . . . . . . . . . . .
Type of work:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preparatory
protective
measures
Which substances are or were present?
Amount / concentration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What substances can form?
Amount / concentration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Existing equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Equipment brought in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Access ports to be cleared:
No. / size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Definition of safety
measures
Vessel to be emptied yes no Type: . . . . . . . .
Residue to be removed yes no Type: . . . . . . . .
Ventilation: natural technical Type:. . . . . . . . . . . . . . . . . . . . .
Air analysis required . . . . . . . . . . . . . . . . . . . . . . . . . . . yes no
Protective breathing equipment required . . . . . . . . . . . yes no
Equipment available or brought in . . . . . . . . . . . . . . . . yes no
if so, what are the safety measures?. . . . . . . . . . . . . . . . . . . . . . . . . .
Personal protective apparel required . . . . . . . . . . . . . . yes no
if so, what protection measures?. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Explosion protection measures required . . . . . . . . . . . yes no
if so, what protection measures?. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Look-out personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes no
Required rescue equipment . . . . . . . . . . . . . . . . . . . . . yes no
Safety measures
cancelled
by. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Safety measures mentioned were observed: . . . . . . . . . . . . . . . . . . .
Approved
from __________ at _______ hrs to __________ at _________ hrs
________________________ ___________________________
(Supervisor) (Contractor or sub-contractor)
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