| Check | Item | Checked By | Remarks |
|---|---|---|---|
| Space ventilated and atmosphere tested | |||
| Lighting and communication devices provided | |||
| Emergency rescue equipment on standby | |||
| Personal protective equipment available | |||
| Work area isolated/secured | |||
| Hot work not permitted simultaneously |
| Test | Result | Time | Tested By |
|---|---|---|---|
| Oxygen (%) | |||
| Flammable Gas (%) | |||
| Toxic Gas (ppm) |
| Issued By (Name/Rank) | |
| Signature | |
| Date/Time |
| Work Completed By | |
| Signature | |
| Date/Time |