Confined Space Entry Permit
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1
2CONFINED SPACE ENTRY PERMIT
Confined Space Location/Description/ID Number
Date:
______________________________________________________________________________________
Purpose of Entry
_____________________________________________________________________________________________
_______________________________________________________________________________
Time In: ______________
Permit Canceled Time: _____________________________________
Time Out: ____________
Reason Permit Canceled: ___________________________________
Supervisor: ___________________________________________________________________________
Rescue and Emergency Services-
Hazards of Confined
Yes
No
Special Requirements
Yes
No
Space
Oxygen deficiency
Hot Work Permit Required
Combustible gas/vapor
Lockout/Tagout
Combustible dust
Lines broken, capped, or blanked
Carbon Monoxide
Purge-flush and vent
Hydrogen Sulfide
Secure Area-Post and Flag
Toxic gas/vapor
Ventilation
Toxic fumes
Other- List:
Skin- chemical hazards
Special Equipment
Electrical hazard
Breathing apparatus- respirator
Mechanical hazard
Escape harness required
Engulfment hazard
Tripod emergency escape unit
Entrapment hazard
Lifelines
Thermal hazard
Lighting (explosive proof/low voltage)
Slip or fall hazard
PPE- goggles, gloves, clothing, etc.
Fire Extinguisher
Communication Procedures:
DO NOT ENTER IF PERMISSABLE ENTRY
Test Start and Stop Time:
LEVELS ARE EXCEEDED
Start
Stop
Permissable Entry Level
% of Oxygen
19.5 % to 23.5 %
% of LEL
Less than 10%
Carbon Monoxide
35 PPM (8 hr.)
Hydrogen Sulfide
10 PPM (8 hr.)
Other
Name(s) or Person(s) testing: ________________________________________________
Test Instrument(s) used- Include Name, Model, Serial Number and Date Last Calibrated:
CFM-Ventilation
Size-Cubic Feet
Pre Entry Time
Central Notified
Time Notified:
Before Entrance
Central Notified
Time Notified:
After Entrance
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