AF1024

Site conducted

• Unit

  Select

1. Master Entry Plan (MEP)

• Is Entry Covered by a CSPT Approved MEP?

  Yes

  No

• Date MEP Approved?

  Date

2. General Information

• On or Off Installation, Location (GPS coordinates if known) & Description of Space to be Entered

• Purpose of Entry

• Identify any TO or OI that Covers Entry

Authorized Duration of Permit

• Date and Time Issued

  Date

• Time Expires

  Date

• 3. Hazards (Indicate all probable hazards)

  Select Oxygen Deficient (<19.5%) Oxygen Enrichment (>23.5%) Material Harmful to Skin Airborne Combustible Dust (≥ LEL or Obscures Vision at Distance of 5ft [1.52M] or Less) Flammable Gases or Vapors (≥ 10% LEL) Mechanical Hazards Electrical Shock Engulfment Other (any other hazards required by applicable TO, OI, etc.)

  • Oxygen Deficient (<19.5%)
  • Oxygen Enrichment (>23.5%)
  • Material Harmful to Skin
  • Airborne Combustible Dust (≥ LEL or Obscures Vision at Distance of 5ft [1.52M] or Less)
  • Flammable Gases or Vapors (≥ 10% LEL)
  • Mechanical Hazards
  • Electrical Shock
  • Engulfment
  • Other (any other hazards required by applicable TO, OI, etc.)

• Describe Other hazards:

4. Hazard Controls

• Personal Protective Equipment

  Yes

  No

• What PPE is needed:

• Respiratory Protection

  Yes

  No

• Describe Respiratory Protection Needed:

• Describe Communication method:

• Rescue Equipment

• Other (any other hazards controls required by applicable TO, OI, etc.)

5. Preparation for Entry (Any item in this section that is inconsistent with MEP is not a routine entry)

• Notification of Service Interruption

• Blank/Blind Lines

• Purge/Clean

• Inert

• Barriers

• Double Blank and Blind

• Isolation Methods

• Electrical Hazardous Energy Control

• Mechanical Hazardous Energy Control

• Atmospheric

Ventilation Methods

• Mechanical

• Natural

Communication Methods

• Visual

• Voice

• Tug Rope

• Radio/LMR

Additional Permits

• AF Form 592, Hot Work Permit

Personnel Awareness

• Signs Posted

• Pre-Entry Briefing on Specific Hazards, Work to be Performed, Control Methods & Emergency Egress

• Pedestrian & Vehicle Barriers

• Other (any other required by applicable TO, OI, etc.)

6. Atmospheric Testing & Monitoring Record (Continuous monitoring shall be performed during all construction confined space operations)

Monitoring Device:

• Make

• Model & S/N

• Date Calibrated

  Date

• Date Bump Tested

  Date

Type Hazard

• Acceptable Entry Conditions Occupational & Environmental Exposure Limits (OEEL)
  Oxygen (O2) 19.2% - 23.5%
  Carbon Monoxide (CO) ≤ 25 PPM
  Flammables (LEL) < 10%

Readings

Oxygen (O2)

• Time

  Date

• Result

Carbon Monoxide (CO)

• Time

  Date

• Result

Flammables (LEL)

• Time

  Date

• Result

Toxic Gases and Vapors - e.g., Sulfur Dioxide (SO2), Chlorine (Cl), Hydrogen Sulfide (H2S), Volatile Organic Compound (VOC), etc

• Type of Toxic Gases and Vapors:

• Time

  Date

• Result

• Atmospheric Monitor(s) Name and Signature

  Sign

• Continuous monitoring required?

  Yes

  No

• Frequency:

• Additional testing/monitoring or entrant information attached?

  Yes

  No

7. Authorized Personnel (All listed authorized supervisors must be consistent with MEP to be a routine entry)

Entry Supervisor(s)

• Grade/Title

• Name (Last, First MI)

• Signature

  Sign
Attendant(s)

• Grade/Title

• Name (Last, First MI)

Entrant(s)

• Grade/Title

• Name (Last, First MI)

8. Fire Emergency Services or Equivalent

• Point of Contact (Last, First MI)

• Contact Info (Phone #, Radio Call Sign, etc.)

• Date/Time Rescue Service Confirmed

  Date

9. Coordination (Not required for entries consistent with an approved MEP)

• Occupational Safety (SEG)

  Sign

• Bioenvironmental (BE)

  Sign

• Fire Emergency Services (FES)

  Sign
10. Entry Time Log

• Name (Last, First MI)

• Time In

  Date

• Time Out

  Date

11. Close-out / Cancellation

• Date/Time Work Completed

  Date

• Date/Time Permit Closed/Cancelled

  Date

• Additional Comments:

• Entry Supervisor Print & Sign

  Sign

This permit must be available on job site during entry