Fort Hamilton Confined Space Entry Permit printable pdf download

Fort Hamilton Confined Space Entry Permit

Issued by the Fort Hamilton Safety Office



Telecom manholes with “no additional hazards” for “normal telecom operations” do not

require a permit, but entry must comply with 29 CFR 1910, 146 and 268.

Date and Time Issued: _______________

Date and Time Expires: _______________________

Job site/Space I.D.: ____________________

Organization: _________________________

Equipment to be worked on: _______________

Work to be performed: ______________

Stand-by personnel: __________________ ________________ __________________

1. Atmospheric Checks:

Time ___________

Oxygen ________ %

Explosive ________ % L.E.L.

Toxic ________ PPM

2. Tester's signature: _____________________________

3. Source isolation (No Entry): N/A Yes No

Pumps or lines blinded, disconnected, or blocked ( ) ( ) ( )

4. Ventilation Modification: N/A Yes No

Mechanical ( ) ( ) ( )

Natural Ventilation only ( ) ( ) ( )

5. Atmospheric check after isolation and ventilation:

Oxygen __________% > 19.5 %

Explosive _______% L.E.L. < 10 %

Toxic ___________PPM < 10 PPM H(2)S

Time ____________

6. Testers signature: _____________________________

7. Communication procedures: ________________________________________

_____________________________________________________________________

Fort Hamilton Safety Form 385-4

Fort Hamilton Confined Space Entry Permit