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Fomulir HSE
Dokumen No.: Halaman:
HSE/FORM-43 1 of 1
CONFINED SPACE ENTRY PERMIT
NO.4
IJIN MASUK RUANG TERTUTUP

NAME OF APPLICATION/SUPERVISOR :
NAMA PEMOHON/SUPERVISOR

DATE : LOCATION : EQUIPMENT :

TANGGAL LOKASI PERALATAN

HAZARD DESCRIPTION :
URAIAN BAHAYA

PRECAUTION REQUIRED :
PENCEGAHAN YG DIPERLUKAN

CHECKLIST/DAFTAR PEMERIKSAAN

(1) ATMOSPHERE TESTING/TEST UDARA

(a) Oxygen Content/Kandungan Oksigen __________ ___________ Result/Time/Date
(b) Explosion Gas/Gas yang bisa meledak __________ ___________ Hasil/Jam/Tanggal
(c) Carbon Monoxide/Karbon Monoksida __________ ___________
(2) VENTILATION REQUIREMENT __________
HARUS ADA VENTILASI
(3) ELECTRICAL HAZARDS __________
BAHAYA LISTRIK
(4) FIRE PROTECTION __________
PEMADAM KEBAKARAN
(5) COMMUNICATION __________
KOMUNIKASI
(6) RESCUE EQUIPMENT __________
PERLENGKAPAN PENYELAMAT

NAME OF EXPOSE EMPLOYEES __________ ___________ ___________

NAMA KARYAWAN YANG TERLIBAT
CHECKED AND SATISFIED __________ ___________ ___________
TELAH DIPERIKSA DALAM KEADAAN BAIK

_________________ _______________________
SUPERVISOR HSE COORDINATOR
(Signature/Tanda Tangan) (Signature/Tanda Tangan)

COMMENT : ______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

_____________________ ________________________
PERSON IN CHARGE SUPERVISOR
(Signature/Tanda Tangan) (Signature off/Ditutup)
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