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i peuetsoI-ASIAN{Persetuiuan Level lsolasidan Metode)

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 OTORISASI DAN.PENERIMAAN IZIN
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CAtAtAN: APABILA TERJADI PERUBAHAN KONDISI DI LOKASI KERJA1UAKA PEMBERI IZIN WAJIB SEGERA DIBERITAHU

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Nama Pem berilzin Departemen; Ttd:

CATAT.AN SIA,VD Bv PERSO^TCONFINED SPACE

HanyaCcnfined Space Sfandby Person yang sahdapatmengencjalikan confined space ini. SetiapConfined Space Sfandby
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Nama Tanggal Jam Mulai Tandatangan Jam Selesai Tandatangan

CATATAN MASUK CONFINED SPACE

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Saya memastikantelahmeninjaupengendaiianbahayasepertiterlulispadaConfined Space Entry Permit
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A copy of this rescue plan shall be maintened by emergency response personnel

,Salfnan rencafia perryelamatan lnl akan disimpan alr'h persanil ERT,

Two-Way Radiolradio 2 arah channel 1 Telephone: A21290499LL

Tick required ERT notification

D I{ubungi berdasarkan kasus y' ttuUungi Sebeium Masuk tr ERT berada di CS sebelum masuk

?a nk/Y*ssel ftankl/HapalJ Enffance PointfPintu Masuk) Extmction Pol nt a nd anchor polnts.[Tltik Tambatan)

100-900-sA-FRM-0021
Staternent M etode Penyelamatan:

iA.fir"t@ akandiambil;
fi. Ennrre att s@ed before approachingvictimfcrrescue
II W*mastfftan semua baiaya sekftarrrya telaft feratssi sehElrm mendekatf korbsn untuk
-^ -.,^t-*a+*a
tf atmosptrereiJsafe, faftertesting] heginprimaryassessment JikaUdara amdn {setelah
test) Lalatkan penilaian utfi ma

i._.-_-1--potentii an po.tensi bahrva I4In:

2, Chance on engUlfrnentwhilst rescue {chemicals, sludge/sewerage, other

hazardous soilds or Iiquids) Perubahan atmosphere scat sementara
_penyetamatan {bahan Mm!q, sladg e 4ruinasa 83 f@1. Ww}-
J. Interral configuration (wet, slippery, poor lighting, sharp obiects etcJ ffondtsi
berbahaya di dalum ruang CS pusufu licin, Kurang pencahayaan, benda taiam
-- - --itt)
4. Electricalhaz4rds,F-,94gylLliltn[-
[- 5; tt{echaftd (moving/rotatinggearl Bahayamekanik{peralaan
L-*__ __*bqpuw/lerprytg.]_ , _
i g. tf atmrsphere is unsafe do ngt enteflJks tJdars fid.rk fltnanr@
4. Externalhazards/BahayadariLuar:
TraEq H4z ar4 I tg@vslql vl:rrqg-
2. Rainlwater Hujan/Air
3. Electrical Listrik
t. sille1gllglts_tdl$si4toqpgl14e$endsrulsJslgb
5. HeatPanrs
6, ERTto Tagoutlog out sa{r,
lre@ / Veltilasifiubang an_git!

100-900-sA-FRM-002L
 Space has configuration that will hamper ventilation Ruangan dengan banyak petak

2. ConvolutedspaceRuanganberliku
3. Large volume Ruangan Eesar
4. Other.Lain-Iafn
Method of rescue Metode
External retrieval Xorban dariluar
.,
Internal Retrieval karban dqri dalam
Ilauling rystem
required f membuat

Patient Lowering
$ystem required
menurunkan karban
mengganakan sytem

tali-temali sebelum di

t 1. Entrants maybe_visuall
b visuallyrbse rved Er
e_ Entrants dapat diamati secara visual
i,_ _ 2. _ __ Voice only_!{!!e igqquate / berslt_a!!J1_g!yg_p.!gayg!tg_!_e$e!g_qr .__...__
, 3. Yisual hanllsigqelq adequate / srnyal_lgnggl*gl\L4-l _^*.- .

l 4. Radi;*q"it" diiatdio di perlukan

Possible retrieval methods / Metode loin sLqt ij pqlsi-
1. Raisingand Lowring

', 9.
*---- obstaclq
:-*Rescu;
lhe!_Ee[_E4derret11gval/_Eqmggt4gy_Wg_4ll
i i; iiom treisth

4.
Additional PPE that '414 lqrybg-sLyslls ylg
.,

IUU-YUU.sA-T.RM-UUI1
 /

Description of sPace

Is conlin*d spare signagain place ves6-o)

1 UU-YUU. 5A- t. KM.UU I, 1