Form B Confined Space Entry Permit
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1FORM B
Confined Space Entry Permit
___________CONFINED SPACE ___________HAZARDOUS AREA
PERMIT VALID FOR 8 HOURS ONLY. ALL COPIES OF PERMIT WILL REMAIN AT JOB SITE UNTIL JOB IS
COMPLETED.
SITE LOCATION AND DESCRIPTION ________________________________________________________________
PURPOSE OF ENTRY_______________________________________________________________________________
SUPERVISOR(S) IN CHARGE OF CREWS
TYPE OF CREW
PHONE #
_________________________________________________________________________________________________
_________________________________________________________________________________________________
*BOLD DENOTES MINIMUM REQUIREMENTS TO BE COMPLETED AND REVIEWED PRIOR TO
ENTRY*
REQUIREMENTS COMPLETED
DATE
TIME
REQUIREMENTS COMPLETED
DATE
TIME
Lock Out/De-energize/Try-out
_____
_____
Full Body Harness w/"D" ring
_____
_____
Line(s) Broken-Capped-Blanked _____
_____
Emerg. Escape retrieval Equip. _____
_____
Purge-Flush and Vent
_____
_____
Lifelines
_____
_____
Ventilation
_____
_____
Fire Extinguishers
_____
_____
Secure Area (Post and Flag)
_____
_____
Lighting (Explosive Proof)
_____
_____
Breathing Apparatus
_____
_____
Protective Clothing
_____
_____
Respirator(s) (Air Purifying)
_____
_____
Resuscitator - Inhalator
_____
_____
Burning and Welding Permit
_____
_____
Standby Safety Personnel
_____
_____
Note: Items that do not apply enter N/A in the blank.
** RECORD CONTINUOUS MONITORING RESULTS EVERY 2 HOURS **
TEST(S) TO BE TAKEN
Permissible Entry Level
PERCENT OF OXYGEN
19.5% to
____ ____ ____ ____ ____ ____ ____ ____
23.5%
____ ____ ____ ____ ____ ____ ____ ____
LOWER FLAMMABLE LIMIT
Under 10%
____ ____ ____ ____ ____ ____ ____ ____
CARBON MONIXIDE
Under35 PPM
____ ____ ____ ____ ____ ____ ____ ____
Hydrogen Sulfide
Under 10 PPM
____ ____ ____ ____ ____ ____ ____ ____
___________________
_____________
____ ____ ____ ____ ____ ____ ____ ____
___________________
_____________
____ ____ ____ ____ ____ ____ ____ ____
REMARKS:
_________________________________________________________________________________________
GAS TESTER NAME
# INSTRUMENT(S) USED
MODEL &/OR TYPE
SERIAL
&/OR UNIT #
___________________
___________________
__________________
__________________
___________________
___________________
__________________
__________________
SAFETY STANDBY PERSON IS REQUIRED FOR ALL CONFINED SPACE WORK
SAFETY STANDBY
PERSON(S):_________________________________________________________________________
SAFETY STANDBY
PERSON(S):_________________________________________________________________________
SAFETY STANDBY
PERSON(S):_________________________________________________________________________
SUPERVISOR AUTHORIZING ENTRY
ALL ABOVE CONDITIONS SATISFIED
__________________________DEPARTMENT____________Phone__________
AMBULANCE 911
FIRE 911
SAFETY 706-3490
CAMPUS POLICE 711
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