Confined Space Entry Permit
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21A. NAME OF EMERGENCY CONTACT
1B. TELEPHONE NUMBER
CONFINED SPACE ENTRY PERMIT
2. SPECIFIC LOCATION OF SPACE
3. DESCRIPTION OF SPACE
A. DATE
B. TIME
4. PURPOSE OF ENTRY
5. ENTRY
A. DATE
B. TIME
6. EXIT
7A. NAME OF SUPERVISOR IN CHARGE OF WORK
7B. TELEPHONE NUMBER
8. NAME OF ENTRANT(S)
9. NAME OF ATTENDANT
10. NAME OF CONFINED SPACE TESTER
11. WELDING OR "HOT WORK" REQUIRED
YES
NO
12. CONFINED SPACE TEST DATA
List specific tests made. Entry is prohibited if reading outside standard permissible entry level(PEL).
B. PERMISSIBLE
A. SUBSTANCE TESTED
C. READING
D. DATE
E. TIME
LEVEL
OXYGEN (%)
>19.5
<22.0
% OF LOWER EXPLOSIVE LIMIT
10%
CARBON MONOXIDE
35 ppm
13A. NAME OF INSTRUMENT(S)
13B. TYPE(S) OF INSTRUMENTS
13C. IDENTIFICATION NUMBER(S)
13D. WHEN LAST CALIBRATED
14. SPECIAL REQUIREMENTS (Explain each "No" answer in Item 18)
YES
NO
ITEM
YES
NO
ITEM
A. LOCKOUT - DE-ENERGIZE (Employee retains key)
I. FIRE EXTINGUISHER
B. SPACE PURGED
J. LIGHTING
C. VENTILATION
K. EMERGENCY TRIPOD
D. AREA SECURED
L. PROTECTIVE CLOTHING
E. BREATHING APPARATUS
M. LINE CAPPED OR BLANKED
F. RESUSCITATOR/INHALATOR
N. RESPIRATOR
G. ESCAPE HARNESS
O.
H. LIFELINE
P.
15. OTHER SPECIAL REQUIREMENTS (List each and status)
16A. SPECIFIC PROTECTIVE CLOTHING AND EQUIPMENT REQUIRED
16B. RESPIRATOR
NEG. PRESS.
SUPPLIED AIR
PAPR
SCBA
17. COMMUNICATION PROCEDURES DURING ENTRY
18. ADDITIONAL COMMENTS/REMARKS
19. RESERVED FOR REGIONAL S&EM DIVISION/BRANCH
20. I CERTIFY THAT I HAVE READ AND UNDERSTOOD ALL OF THE REQUIREMENTS OF THE CONFINED SPACE ENTRY PROGRAM IMPLEMENTED BY MY GSA
FACILITY MANAGER. FURTHERMORE, I WILL COMPLY WITH ALL OF THESE CRITERIA.
ENTRANT
ATTENDANT
SIGN AND
SIGN AND
DATE HERE
DATE HERE
21. I CERTIFY THAT ALL OF THE ABOVE INFORMATION IS CORRECT AND THE SPACE ENTRANT AND ATTENDANT ARE FULLY COMPETENT TO PERFORM WORK
DESCRIBED IN THE ABOVE CONFINED SPACE.
DATE
SUPERVISOR
SIGN HERE
GENERAL SERVICES ADMINISTRATION
GSA FORM 3625 (10-91)
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