Confined Space Emergency Rescue Services Notification - Maine Safety And Environmental Management Department

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Department:
The University of Maine Safety and Environmental Management Department
Page 1
Document:
Confined Space Emergency Rescue Services Notification
MF10038, 10/23/09, Rev 4
Confined Space Emergency Rescue Services Notification
Section I - Contact Information for Confined Space Site
(Contact Information is Critical and Required in order to activate the Confined Space Permit)
Date: ________________, 20______
Time: ____________________________ Public Safety Official ______________________
Caller ____________________________
Phone or Radio # ______________________ Department _________________________
All spaces below must be completed in order to activate Permit
Supervisor: _______________________________
Phone or Radio # __________________________
Attendant: ________________________________
Phone or Radio # __________________________
The attendant remains outside of the confined space, at the site and in communication with both UMDPS and the people inside the confined
space at all times. (Cell #.)
Detailed Location of the confined space REQUIRED: (This should include closest building and direction and distance from the bldg)
1) _________________________ Time in ____________
Time out___________
Location(s) _____________________________
2) _________________________ Time in ____________
Time out ___________
Location(s) _____________________________
3) _________________________ Time in ____________
Time out ___________
Location(s) _____________________________
4) _________________________ Time in _____________ Time out ___________
Location(s) _____________________________
5) _________________________ Time in _____________ Time out ___________
Location(s) _____________________________
6) _________________________ Time in _____________ Time out ___________
Location(s) _____________________________
7) _________________________ Time in _____________ Time out ___________
Location(s) _____________________________
8) _________________________ Time in _____________ Time out ___________
Location(s) _____________________________
* If two manholes are connected as in a video-cam/video snake task, please indicate on the numbered line above and discuss thoroughly with Public Safety.
Section II - Notification Section
Before an entry can be made into a permit-required confined space, rescue services must be available. After fire Department approval, monitor
the fire department’s radio frequency, if rescue services become unavailable, all permits must be immediately terminated. (Call the attendant(s)).
Orono Fire Department: 866-4000 Fire Department Available: YES NO (circle one) Time: _________________________________
Old Town Fire Department: 827-3400 Fire Department Available: YES NO (circle one) Time: _______________________________
If PRCC answers; have appropriate fire supervisor contact UMPD directly before entry can be made.
Fire Department & Contact Person ________________________________________________________________________________
Time Supervisor notified of Rescue Services availability: ______________________________________________________________
Now fax copy of this form to the fire department: Orono 866-5056; Old Town 827-3976 & Safety & Environmental Mgmt (SEM) 1-4085
Section III - Confined Space Entry Completion
Supervisor / UMPD Official (circle one) terminated entry: Time ___________________
Date: ___________________
Fire Department Notified: Time __________________Date: _______________ after completion Fax to 1-4085. If FM, also Fax to 1-2673.

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