Title Page

    Site conducted
  • Unit


1. Master Entry Plan (MEP)

  • Is Entry Covered by a CSPT Approved MEP?

  • Date MEP Approved?

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

  • Time Expires

  • 3. Hazards (Indicate all probable hazards)

  • Describe Other hazards:

4. Hazard Controls

  • Personal Protective Equipment

  • What PPE is needed:

  • Respiratory Protection

  • 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 Bump Tested

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

  • Result

Carbon Monoxide (CO)

  • Time

  • Result

Flammables (LEL)

  • Time

  • 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

  • Result

  • Atmospheric Monitor(s) Name and Signature

  • Continuous monitoring required?

  • Frequency:

  • Additional testing/monitoring or entrant information attached?

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

  • 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

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

  • Occupational Safety (SEG)

  • Bioenvironmental (BE)

  • Fire Emergency Services (FES)

  • 10. Entry Time Log
  • Name (Last, First MI)

  • Time In

  • Time Out

11. Close-out / Cancellation

  • Date/Time Work Completed

  • Date/Time Permit Closed/Cancelled

  • Additional Comments:

  • Entry Supervisor Print & Sign

This permit must be available on job site during entry

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