QES Management System
Issue Date: 18/12/2014
Application to Access/Enter Confined Spaces
Permit Number (Office Use only)
CWW Contact Person:
File/Project No.:
Location Address:
Melways Ref:
Manhole Numbers:
Application for:
(please circle)


Non Entry Works Only
Confined Space Entry
Type of Works:
(Please circle)
Date of Access – From
To:
Time of Access – From
To:
Company Name:
Postal Address:
Site Contact Name:
Contact Phone:
Office Contact Name:
Contact Phone:
Office email address:
Office Fax:




MH Alteration
Plug Insertion
Plug Removal



CCTV
New Branch
Other
Inspection
Name(s) of Person(s) Entering/Accessing Confined Space:
ALL CONTRACTORS MUST COMPLY WITH CWW’S CONDITIONS AS HIGHLIGHTED BELOW AND THOSE CONTAINED IN CWW’S
RESPONSE TO THIS APPLICATION:



All parties entering manholes are to be familiar with and carry out works in accordance with the OH&S Regulations 2007, AS2865
“Confined Spaces” and City West Water’s ‘PRO-69 Confined Space Entry and Associated Works’ Procedure.
If manholes to be accessed are located within private property, you the contractor must notify property owners 3 days in advance and
gain permission to access their property.
All your safety equipment and machinery must be well maintained and a service history kept as proof of service intervals.
The following information/documentation must be submitted along with this application:

Copies of each of your employees / sub-contractors current Confined Space Entry Tickets.

Copy of proposed Safe Work Method Statement.

Copy of submitted ‘Notification of Intention to Commence Excavation Operations in Trenches, Shafts and Tunnels (if applicable)’.

A site map indicating the location of the proposed works.
During inspection of this sewer / manhole(s) the contractor must :

Check prior to entering any manhole that entry is safe and complete checklist.

Wear and use correct safety gear and work in a responsible safe manner.

Keep disruption to residents to a minimum.

Reinstate all manhole covers and leave site clean and safe.
As the contractor, l understand that it is my responsibility to ensure that all parties engaged in entering/accessing
City West Water’s assets strictly comply with all the above conditions.
SIGNED ___________________________________________
DATE _____ / _____ / ______
Access Notification is to be made at least five (5) days prior to entry of any manholes.
Send this sheet to the – Operational Control Centre via Email: [email protected]
Enquiries & Call In/Out Telephone No. 1800 057 981
Document FOR-159
Rev 3
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