Confined Space Entry Permit Page 2
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1
2PERMIT MUST REMAIN POSTED AT JOB SITE AT ALL TIMES.
Air Monitoring Equipment Data
Calibration By: _______________ ________ Department:____________
Manufacturer
Model #
Instrument #
Atmospheric Testing Data
Location of
%Oxygen
Flamm
Carbon
Hydrogen
Other Toxics
Atmosphere
Date
Time
Reading
(19.5% To
%LEL
Monoxide
Sulfide
Tested By
23.5%)
(Below
CO
H2S
Initials
10%)
(Below 25
(Below 5
ppm)
ppm)
1
2
NOTE:
Testing results shall be recorded at a minimum of at least twice per hour, continuous monitoring preferred.
______________________________________________________________________________
Permit Authorization
Entry Authorization / Supervisor Signature
Time
Date
____________________________________________
______
_______
The entry authorization signature certifies that all precautions and equipment specified by this permit are in place and all
atmospheric testing is within allowable limits to allow entry.
Cancellation of Permit
Permit Cancellation Signature (Entry Supervisor)
Time
Date
______
______
or an
The entry supervisor cancels the permit when the work authorized by the permit is completed
unacceptable condition has
occurred.
____________________________________________________________________________
_
Emergency: If an entry rescue is required, only a properly trained and protected entry Attendant or Entry Supervisor may enter the
space to rescue the victim; and he/she MUST call the City of Atlanta Fire Department: 9-911 or Georgia Tech Police at (404) 894-
2500 and immediately notify the EHS Department at (404) 216-5237.
Georgia Tech/ EHS Office
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