Confined Space Entry Form And Permit
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CONFINED SPACE ENTRY FORM & PERMIT
Instructions: Top half of form must be completed prior to entry into any non-permit confined space.
Top AND Bottom half of form (the Permit) must be completed prior to entry into any PERMIT-REQUIRED space.
Date of entry:
Time of Entry:
Location: ________________________________ Type of space:_______________________
Equipment to be worked on:
Work to be performed & TMA #:
Anticipated time needed to complete work:_________________________________________
Anticipated Harzards:__________________________________________________________
Entry personnel: ____________________________________________________________________
Attendants:
Acceptable conditions
1.
Atmospheric checks:
Oxygen
% O
19.5 % to 23.5 %
2
‹10% L.E.L./L.F.L.
Explosive
% L.F.L.
Toxic
ppm
0-35 ppm Carbon Monoxide
0-10 ppm Hydrogen Sulfide
Atmospheric Tester's Initials:_____________________ Time:_____________________
2.
Isolation of pumps/lines:
N/A
Yes
No
Pumps or lines blocked,
( )
( )
( )
blinked, or disconnected
3.
Ventilation:
N/A
Yes
No
Mechanical
( )
( )
( )
Natural ventilation only
( )
( )
( )
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CONFINED SPACE ENTRY PERMIT (In addition to the above items, the following must be checked,
verified, and completed prior to entry in any PERMIT-REQUIRED SPACE
Entry cannot be performed if any boxes are marked "No." This permit is valid for 8 hours only.
4.
Hot work permit required
( )
( )
( )
5.
Atmospheric checks after isolation and ventilation, if applicable:
Oxygen:
% O
2
Explosive:
% L.E.L
Toxic:
PPM
6.
Communication procedures:
7.
Lockout procedures, if applicable:
8.
Entrant(s) and attendant(s) have
Yes
No
successfully completed required training.
( )
( )
9.
Attendant has means of communication to Fire Dept. for rescue
( )
( )
10.
Equipment:
N/A
Yes
No
Direct reading sampling device which is properly calibrated
( )
( )
( )
Safety harnesses and lifelines for entrants and attendants
( )
( )
( )
Mechanical retrieval/hosting equipment
( )
( )
( )
Communication equipment
( )
( )
( )
SCBA or Type C air line respirator
( )
( )
( )
Personal protective equipment and clothing
( )
( )
( )
Electrical equipment/Lighting/Non sparking Tools
( )
( )
( )
Traffic barriers/entrance covers
( )
( )
( )
I have reviewed the work authorized by this permit and the information pertaining to each item. Safety
procedures have been received and are understood by all personnel.
Entry Supervisor Signature:
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