Ballast Tank Cleaning Work Permit
| Permit No. |
|
Date Issued |
|
| Vessel Name |
|
Location |
|
| Tank(s) Involved |
|
Description of Work
Work Start Date & Time
Expected Work Completion
Personnel Involved
Hazards Identified
Precautionary Measures
Personal Protective Equipment Required
Atmospheric Testing Results (if applicable)
| Test |
Result |
Time |
Tester |
| Oxygen Level (%) |
|
|
|
| LEL (%) |
|
|
|
| Other |
|
|
|
Isolation Procedures Applied
Special Instructions
Emergency Arrangements
Permit Issuer (Signature & Date)
Person in Charge of Work (Signature & Date)
Officer on Duty (Signature & Date)