Confined Space Permit
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1Available online or as 3-Part Form #1368 at OU Print Shop (revised 10/99)
Permit-Required Confined Space
ENTRY PERMIT
PERMIT VALID FOR _____ HOURS OR UNTIL FOLLOWING JOB IS COMPLETE:_____________________________________________________
Site Location and Description
Purpose of Entry
Entry Supervisor__________________________________________________ Unit Supervisor ___________________________________________________
Name(s) of Authorized Entrant(s)
* BOLD DENOTES MINIMUM REQUIREMENTS TO BE COMPLETED AND REVIEW PRIOR TO ENTRY *
[NOTE: Enter N/A in the items that do not apply]
REQUIREMENTS COMPLETED
DATE
TIME
REQUIREMENTS COMPLETED
DATE TIME
Lock Out/De-energize/Try-out
______ _____
Emergency Escape Retrieval Equip
_____ _____
Line(s) Broken-Capped-Blanked
______ _____
Lifeline(s)
_____ _____
Purge-Flush and Vent
______ _____
Fire Extinguishers
_____ _____
Mechanical Ventilation
______ _____
Lighting (Explosive Proof)
_____ _____
Secure Area (Post and Place Barriers)
______ _____
Protective Clothing
_____ _____
Full Body Harness w/ "D" Ring
______ _____
Burning and Welding Permit (Hot Work)
_____ _____
** RECORD CONTINUOUS MONITORING RESULTS EVERY TWO (2) HOURS **
CONTINUOUS MONITORING RESULTS:
Permissible Entry Levels
Times:
____
____
____
____
____
____
____
____
Percent of Oxygen
19.5% to 23.5%
____
____
____
____
____
____
____
____
Lower Flammable Limit
Under 10%
____
____
____
____
____
____
____
____
Carbon Monoxide
35 PPM
____
____
____
____
____
____
____
____
a
b
Aromatic Hydrocarbon
1 PPM
5 PPM
____
____
____
____
____
____
____
____
b
Hydrogen Cyanide
(Skin)
4 PPM
____
____
____
____
____
____
____
____
a
b
Hydrogen Sulfide
10 PPM
15 PPM
____
____
____
____
____
____
____
____
a
b
Sulfur Dioxide
2 PPM
5 PPM
____
____
____
____
____
____
____
____
b
Ammonia
35 PPM
____
____
____
____
____
____
____
____
Other _____________________________
_______ ________
____
____
____
____
____
____
____
____
a
b
Employees can work in the area for 8 hours at this concentration
Employee can work in the area up to 15 minutes at this concentration
Gas Tester Name:_________________________
Instrument Used Model # &/or Type &/or Serial # ______________________________________________
Name of Attendant
Entry Supervisor Name (Printed)____________________________________________________________
All Above Conditions Satisfied (Entry Supervisor Signature) _____________________________________
EMERGENCY 911
Dept ___________________________________ Phone ____________ Date _______________________
EH&S 4196
Distribution: Supervisor; EH&S; Hard Copy - Posted at Entrance to Confined Space
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