Fort Hamilton Confined Space Entry Permit (Page 2 of 3) in pdf

Fort Hamilton Confined Space Entry Permit

8. Rescue procedures: _______________________________________________

_____________________________________________________________________

9. Entry, standby, and back up persons: Yes No

Successfully completed required training? ( ) ( )

Is it current? ( ) ( )

10. Equipment: N/A Yes No

Direct reading gas monitor tested? ( ) ( ) ( )

Safety harnesses and lifelines for entry and standby persons? ( ) ( ) ( )

Hoisting equipment? ( ) ( ) ( )

Powered communications? ( ) ( ) ( )

SCBA's for entry and standby persons? ( ) ( ) ( )

Protective Clothing? ( ) ( ) ( )

All electric equipment listed Class I, Division I, Group D, and non-sparking tools? ( ) ( ) ( )

11. Periodic atmospheric tests:

Oxygen ____%

Time ______ Oxygen ____%

Time ______

Oxygen ____%

Time ______ Oxygen ____%

Time ______

Explosive ____% Time ______ Explosive ____% Time ______

Toxic _____%

Time ______ Toxic ____%

Time ______

Toxic _____%

Time ______ Toxic ____%

Time ______

Continue readings on back of permit if required.

We have reviewed the work authorized by this permit and the information contained herein. Written

instructions and safety procedures have been received and are understood. Entry cannot be

approved if any squares are marked in the "No" column. This permit is not valid unless all

appropriate items are completed and all names / signatures are present. This permit is valid for 8

hours or one work shift, whichever is shorter in duration.

Permit Prepared By: (Confined Space Coordinator) __________________/_________________

Reviewed By: (Entry “On-Sight” Supervisor) ___________________/_____________________

Approved By: (Organization Supervisor) _____________________/_____________________

Final Review By: (Fort Hamilton Safety Office) _________________/___________________

(printed name) (signature)

Permit cancelled by ___________________________________________________________

Permit cancelled due to _________________________________________________________

Cancellation Date ____________ Time: _____________

Fort Hamilton Safety Form 385-4

Fort Hamilton Confined Space Entry Permit Page 2