ASANKO GOLD MINE LIMITED

DOCUMENT TITLE: CONFINED SPACE ENTRY PERMIT FORM

COMPILED BY: SAFETY TEAM REVIEWED BY: UNIT MANAGER- SAFETY APPROVED BY: MANAGER - SHS
DOCUMENT NUMBER: AGM/SHS/PTW/08/003 ISSUE NUMBER: 03
Page 1 of 3 COMPLETION DATE: 20/10/2015 REVIEW DATE: 24/05/2020 APRROVAL DATE: 01/06/2020

Part 1 General Information *Permit only valid until end of shift*

Date Issued:_________________ Location of Work:________________________________ Time:___________
Description of Work:_______________________________________________________________________________
_________________________________________________________________________________________________
Permit Requestor:___________________________ Duration of Permit:________________

Part 2 Permit Space Hazards (tick) Part 3 Preparation for Entry (tick)
Oxygen Deficiency Falling Material
 Notification of affected section of services interruption.

Mechanical Ventilation
Relevant personnel trained and aware of hazards
Electricity Fall from Height
 Pre-entry briefing on specific hazards and control methods
Rotating Machinery Manual Handling
Noise Toxic Chemical
 Entrants/standby personnel trained

Vibration Welding arc / fumes  Standby personnel informed to continuously posted outside the
confined space
Illumination Toxic Atmosphere
Dust Sludge / deposits
 Hazard controls, PPE appropriate, reviewed through risk
assessment adequate
Access / egress Hot Humid Conditions
Additional permit required
 Hot work
 Working at height
 Low/high voltage work
Smoking forbidden
Part 4 Atmospheric Checks Part 5 Isolation Plan
*Continuous atmospheric monitoring is required for the duration of the  De-energize/try out
confined space entry  Lines, broken-capped-blanked
*NOTE: Continuous monitoring results must be recorded every 2 hours  Lock out/ Tag out
Make/Model_________________  Area secured (post and flag)
Date of last calibration_____________  Pumps/lines, blinded, disconnected or blocked, locked out/tagged
 Warning notices
Atmospheric Acceptable Initial Actual Actual Actual Actual Actual Actual Part 6 Personal Protective Equipment (tick)
Testing Level Result result result result result result result  Respiratory protection
Oxygen 19.5-22.5%  Harness/lifelines
 Eye protection
Hydrogen TWA/STEL
Cyanide
 Hand protection
Hydrogen TWA/STEL  Safety helmet
Sulfide  Protective clothing
Carbon TWA/STEL  Hearing protection
Monoxide Part 7 Check required Emergency Equipment
Methane CH4 TWA  Fire extinguisher
/LEL
 Safety harness
Time Read: Time Read: Time Read: Time Read: Time Read: Time Read: Time Read:
 Lifeline/retrieval line
 Radio
 Tripod winch
Tester’s Signature:___________________________  Stretcher
 Resuscitator
 First aid box
 Breathing apparatus
Other (specify)
 ASANKO GOLD MINE LIMITED
DOCUMENT TITLE: CONFINED SPACE ENTRY PERMIT FORM
COMPILED BY: SAFETY TEAM REVIEWED BY: UNIT MANAGER- SAFETY APPROVED BY: MANAGER - SHS
DOCUMENT NUMBER: AGM/SHS/PTW/08/003 ISSUE NUMBER: 03
Page 2 of 3 COMPLETION DATE: 20/10/2015 REVIEW DATE: 24/05/2020 APRROVAL DATE: 01/06/2020

Part 9 List all Authorized Entrants and Standby Personnel

Standby Personnel Badge # Signature Date Time On Time Off

Entrants Names Badge No. Time Time Time Time Time Time Time Time Time Time Time Time
In Out In Out In Out In Out In Out In Out

Please use supplementary sheet Part for additional entrant

Part 10 Rescue / Emergency Plan

Is ERT informed? YES NO

Is rescue plan available for the duration of the specific activities?

Is required equipment available at work area?

Is method of communication and rescue discussed?

___________________________ _______________________________ ______________________

Name of ER Officer Signature Date

COMMENTS:
……………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………………………
Emergency contacts: 0505 468 688, Radio Channel 1, Desk Phone 1111 OR For all Esaase Emergencies, Contact: 0501473000, Channel 10, Desk Phone 2222

Part 11 Authorization
I certify that the requirements of this permit have been met
Area Custodian/Supervisor ________________________ _______________________________ _____________________
Name Signature Date
Permit Authorizer ___________________________ _______________________________ ______________________
Name Signature Date
 ASANKO GOLD MINE LIMITED
DOCUMENT TITLE: CONFINED SPACE ENTRY PERMIT FORM
COMPILED BY: SAFETY TEAM REVIEWED BY: UNIT MANAGER- SAFETY APPROVED BY: MANAGER - SHS
DOCUMENT NUMBER: AGM/SHS/PTW/08/003 ISSUE NUMBER: 03
Page 3 of 3 COMPLETION DATE: 20/10/2015 REVIEW DATE: 24/05/2020 APRROVAL DATE: 01/06/2020

Part 12 Permit Closure (must be signed by the Permit Authorizer after work is completed)
The work was done in accordance with this permit.
Permit Authorizer: ___________________________________ ___________________ ____________
Name Signature: Date:
NOTE: if the conditions or procedures specified on this permit change, STOP WORK IMMEDIATELY AND inform your Supervisor.

 When confined space entry is completed, send this permit to the Safety Officer.
 This permit must be posted on job site. Good only on indicated date.
Entrants Badge No. Time Time Time Time Time Time Time Time Time Time Time Time
in Out in out in out in out in out in out