Confined Space Permit - State Of Mn
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1State of MN – CONFINED SPACE PERMIT
SECTION I – Safe Work Planning (Maximum Duration of Permit is One Working Shift)
Description of space
Reason
Area/Phase
To be entered:
For Entry:
INDIVIDUALS ENTERING CONFINED SPACE
(If more individuals need to be listed, create an attachment to this form.)
1.
2.
3.
SAFETY ATTENDANT:
Date/Time of Actual Work
From:
To:
(Maximum–One Shift)
(Date)
(Time)
(Date)
(Time)
Hazard Identification and
Preventive Measures
Description of Job Hazards:
Mixer/Agitator
Welding Fumes
Steam
Engulfment/Water
Product Infeed
Slippery Conditions
Fall Hazards
Other: List below
Other Mechanical
High Temperature
Chemical
Safety Glasses
Protective Clothing
Faceshield
Other: List below
Identify the Required
Personal
Goggles
Rubber Boots
Gloves: Type
Head Protection
Hearing Protection
Respiratory: Type
Protective Equipment:
Special Instructions:
Include all other PPE Needs
XXXXXXXXXXXXXXXXXXXXXXXXXXXX
YES
N/A
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
YES
N/A
Lockout Required?
Fall Protection Lifeline
Area Barricaded (Taped off, Signs)
Line/Vessel Flushed or Inerted
Ventilation/Air Movers Required?
Continuous Air Monitoring Required?
Lighting/Equipment/Tools (Low Voltage/GFCI)
Respirator Protection Required?
Tripod/Hoist Escape Unit
Communication Devices Required?
Harness/Wristlets/Retrieval Line
Respirator Protection Required?
Infeed Lines blanked/disconnected.
SECTION II– Required Air Monitoring
NOTE: Initial test(s) must be conducted prior to beginning work to verify space conditions. Testing must be done continuously while work is
in progress.
Continuous (During entry testing results must be documented at least once every 60 minutes.)
FREQUENCY:
TIMES MONITORED/
INITIALS OF TESTER
CONTAMINANT
ENTRY LIMITS
PRE-ENTRY
TESTS DURING ENTRY
TESTS
OXYGEN
19.5% - 23.5%
(O
)
2
L.E.L
Below 10%
(Combustibles)
Hydrogen Sulfide
10.0 PPM
(H
S)
OR LESS
2
Carbon Monoxide
35 PPM
(CO)
OR LESS
OTHER:
INSTRUMENT(S) USED
TYPE/ID #
CALIBRATION DATE
FIELD TESTED
PERSON TESTING
YES NO
YES NO
Is space eligible for reclassification to non-permit YES NO
SECTION III– Work Approval (Maximum-One Working Shift) Print and Initial
ENTRY SUPERVISOR
( Maintenance Team Leader or Contractor Foreman)
Entry Supervisor (Print and Initial)
Department Supervisor
Department Supervisor (Print and Initial)
SECTION IV– PERMIT CLOSURE Follow-up/New Safe Work Permit Issued
Job completed and site cleaned; all blanks, tags and locks removed; barricades
YES
Has assigned work been completed?
removed; and equipment checked for leaks, guards replaced, etc.
NO
New Safe Work Permit will be required to complete assigned work.
Note any problems encountered during
entry:
ENTRY SUPERVISOR:
SIGNATURE
DATE/TIME
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