Public Works Authority

Degrémont and all companies of the Group operate

under the brand SUEZ environnement

DRAINAGE AFFAIRS
PROJECT DEPARTMENT
P.O. BOX 22188
TEL. 4495 0000 & 4495 0999 FAX. 4431 7015

DOHA WEST SEWAGE TREATMENT WORKS

EXTENSION N° 5
CIVIL PROJECT C807
PROJECT CODE IA 14/15 C077 G
BUDGET REFERENCE
CONSULTANT

CONTRACTOR

SUB CONTRACTOR CIVIL DESIGNER

TITLE

HEALTH and SAFETY

CONFINED SPACE -
ENTRY PERMIT Form
ALL RIGHTS RESERVED FOR ALL COUNTRIES

DGT JOB NUMBER

SCALE DATE DRAWN UP CHECKED APPROVED

Guilaume
29/08/16 Guilhem JOLY Guilhem JOLY
PEYRISSAGUET
B-000874
COMPANY FORMA TYPE ZONE NUMBER REV. VERSIO DOCUMENT COMMENTS STATUS
T N STATUS
JVT X QS 000 053 C 0 FC
 C 29/08/16 Addition of entrant in/out list (page 7) G. JOLY G. JOLY G. PEYRISSAGUET

B 24/06/15 Modification after consultant comments G. JOLY G. JOLY G. PEYRISSAGUET

- Addition of Presentation sheet
- Addition of responsibility mentions

A 06/05/15 First issue G. JOLY G. JOLY G. PEYRISSAGUET

Rev Date Aim of revision Issue by Checked by Approved by

03/12/2021 513957154.xlsx 3/9

 DOHA WEST - Sewage Treatment Plant Contract N#: B-000874
Health, Safety & Environment Doc N#: JVT-X-QS-000-052
CONFINED SPACE - r. C Doc Status: FC
ENTRY PERMIT Page 3 Date: 29/08/2016

Purpose:
This form is to be used as a Confined Space Work Permit and to record all activities conducted in order to ensure the safe
entrance and work in the Confined Space

Scope:
This document applies to all activities under the responsibility of Degrémont Marubeni JV Doha West Extension 5 Project.

To be carried out by:

Title Main Role
Work Supervisor Prepare the list of equipment using this form. Ensure that all equipment are present and in proper
order before starting the entrance in the Confined Space
HSE Officer Authorize the work in the Confined Space and check that all required equipment are identified and
availlable
Project Manager Authorize the work in the Confined Space
Attendant Check that all required equipment are present before authorizing the entry. Record on this document
each step of the process. Sign the Entry Permit once the job is completed to close the dedicated Entry
Permit
Entrant Check that all required equipment are present before entry. Sign the Entry Permit once the job is
completed to make sure he has exited the Confined Space

References:
JVT-W-QS-000-001 JV HSE Management Plan
JVT-W-QS-000-051 Confined Space Entry procedure
JVT-W-QS-000-052 Confined Space Entry Authorization
JVT-W-QS-000-030 Work permit procedure
JVT-W-QS-000-025 Job Hazard Analysis form

Definitions:
Confined Space Refer to Confined Space Entry procedure
 DOHA WEST - Sewage Treatment Plant Contract N#: B-000874
Health, Safety & Environment Doc N#: JVT-X-QS-000-053
CONFINED SPACE - r. C Doc Status: FC
ENTRY PERMIT
Pages 4 to 7 Date: 29/08/2016

CS Entry Permit # Date CSE Authorization #

Identification of the Operation

Confined Space name

Location

IDENTIFICATION
IDENTIFICATION

Depth Confined Space volume

Specific hazard identified

Nature of Work

Method Statement # Work Order #

1. Nature of Atmosphere
H2S CH4 Cl2 CO NO2 Lack of Oxygen
SO2 NH3 O3 CO2 Others:

2. Determination of Equipment (last column "On site ?" to be used as check list prior to opening)
Characteristics Needed Quantity Available On site?
Signs X
Ventilation X
Gas Detector X
Self Rescue Mask
SCBA
Lighting system (24V max) X
Entry access mean X
Harness
CONFINED SPACE - WORK PERMIT

CONFINED SPACE - WORK PERMIT

Anti-fall / fall-arrester
Safety lanyard / Safety rope X
Evacuation equipment X
Tripod
Safety helmet X
Goggles X
Face shield
Coverall X
Gloves X
Safety shoes/boots X
Life Buoy
First aid kit X
Stop non-authorized entry X
Communication means X
Horn X
Other (to be specified)

Page 5 of 9
 DOHA WEST - Sewage Treatment Plant Contract N#: B-000874
Health, Safety & Environment Doc N#: JVT-X-QS-000-053
CONFINED SPACE - r. C Doc Status: FC
ENTRY PERMIT
Pages 4 to 7 Date: 29/08/2016

CS Entry Permit # Date CSE Authorization #

3. Composition of the crew

Name Function Accreditation Authorized

IDENTIFICATION
IDENTIFICATION

Work Supervisor X
Attendant X
H&S Coordinator
Entrant 1 X
Entrant 2
Entrant 3
Entrant 4

4. Emergency Plan
CONFINED SPACE - WORK PERMIT

CONFINED SPACE - WORK PERMIT

In case of fall, in case of entrant fainting, in case of high level of gas, etc.

5. Work Permit Autorisation

Work Supervisor Project Manager HSE Officer

I ensured that the safety precautions are I understand these work hazards and ensured I have checked the above conditions and
sufficient. that operatives know them consider it safe for this work.

5. Before opening the Confined Space

Check list prior to opening Arrival time on site
Method Statement prepared Work permit signed Draining done Cleaning done
Risk assessment consulted Secure & marked working area

Before opening O2 CO CO2 H2S CH4

OPERATION REPORT

OPERATION REPORT

Measure
Is it ok to open the Confined Space? Yes No
Attendant Signature
Opening date
pre-opening
Opening Hour
Entry Confined Space Mid-Eight Bottom
O2
Ventillation

CO
Before

CO2
H2S

Page 6 of 9
 ION REPORT
OPERATION DOHA WEST - Sewage Treatment Plant Contract N#: B-000874
Health, Safety & Environment Doc N#: JVT-X-QS-000-053
CONFINED SPACE - r. C Doc Status: FC

Ventillation
Before ENTRY PERMIT
Pages 4 to 7 Date: 29/08/2016

CS Entry Permit # Date CSE Authorization #

CH4

6. Forced Ventilation

IDENTIFICATION
IDENTIFICATION

Forced ventilation required Yes No If Yes, flow needed m3/h

Position of blower Blower used m3/h
Starting time of the Blower
Entry Confined Space Mid-Eight Bottom
O2
CO
Entrance
Before

CO2
H2S
CH4
Is the entry in the Confined Space authorized? Yes No

7. During the Confined Space entrance

Entrance date Entrance Hour Number Entrant
Operations report (Entrance/Exit, Gas monitoring, Events)
OPERATION REPORT

OPERATION REPORT

In case of Alarm, Call 7449 2228 (O&M Control Room)

Entry Confined Space Mid-Eight Bottom
O2
CO
CO2
Page 7 of 9
 DOHA WEST - Sewage Treatment Plant Contract N#: B-000874
Health, Safety & Environment Doc N#: JVT-X-QS-000-053
CONFINED SPACE - r. C Doc Status: FC
ENTRY PERMIT
Pages 4 to 7 Date: 29/08/2016

CS Entry Permit # Date CSE Authorization #

H2S
CH4

IDENTIFICATION
IDENTIFICATION

8. Monitoring of In and Out of Entrants

Name
In time
Out time
In time
Out time
In time
Out time
In time
Out time
In time
Out time
In time
Out time
In time
Out time
Name
In time
Out time
OPERATION REPORT

OPERATION REPORT
In time
Out time
In time
Out time
In time
Out time
In time
Out time
In time
Out time
In time
Out time
Name
In time
Out time
In time
Out time
In time
Out time
In time
Out time
In time
Out time
In time
Out time
In time
Out time
9. Closing the Confined Space
Closing date Closing Hour Number Entrant
Restart of operation Time
Work Supervisor Attendant HSE Officer
CLOSING

CLOSING

All the persons under my orders exited the Space. All the persons under my orders exited the Space.
The collective protections are back. The collective protections are back. I acknowledge the closing of the Entry Permit
Page 8 of 9
 DOHA WEST - Sewage Treatment Plant Contract N#: B-000874
Health, Safety & Environment Doc N#: JVT-X-QS-000-053
CONFINED SPACE - r. C Doc Status: FC
ENTRY PERMIT
Pages 4 to 7 Date: 29/08/2016
CLOSING

CLOSING
CS Entry Permit # Date CSE Authorization #
All the persons under my orders exited the Space. All the persons under my orders exited the Space.
The collective protections are back. The collective protections are back. I acknowledge the closing of the Entry Permit
Entrant 1: Entrant 2: Entrant 3:

IDENTIFICATION
IDENTIFICATION

I have exited the Confined Space I have exited the Confined Space I have exited the Confined Space

Page 9 of 9