Atmospheric Testing Prior to Entry

Atmospheric Test Results Prior to Entry

Atmospheric Testing Conducted By

Tester/Equipment Used

Initial Atmospheric Test Results

Oxygen Concentration - (19.5% minimum/23.5% maximum)
Combustible Vapor Concentration (10% LEL maximum)
Carbon Monoxide Concentration (35 ppm maximum)
Hydrogen Sulfide Concentration (10 ppm maximum)

Other Toxin(s) - Specify

Second Atmospheric Test Results (Following 30 minutes of adequate ventilation)

Oxygen Concentration - (19.5% minimum/23.5% maximum)
Combustible Vapor Concentration (10% LEL maximum)
Carbon Monoxide Concentration (35 ppm maximum)
Hydrogen Sulfide Concentration (10 ppm maximum)

Other Toxin(s) - Specify

Nature of Known or Potential Hazards

Oxygen Deficient or Rich Atmosphere

Flammable Vapors (Greater than 10% LEL)

Toxins (Greater than specified or PEL)

Mechanical

Electrical

Corrosive or Skin Irritant

Engulfment

Other - specify

Preparation

Notification of Affected Personnel

Isolation

Lockout/Tagout

Cleaning/Purging

Ventilation (30 minutes minimum)

Emergency Responders Available

Entrant(s)/Attendant(s) Informed of Hazards

Third Person Within Radio Calling Distance

Equipment Required for Entry and Work

Rescue Harness and Lifeline

Protective Clothing

Other PPE

Approved Lighting

Fire Extinguisher

Electrical Tools (Low Voltage, GFI, Approved)

Respiratory Protection - Specify

Communication Aid - Specify

If a hazardous atmosphere is detected during entry, remove employees immediately and re-evaluate the space to determine how the hazardous atmosphere developed. Take measures to protect employees before subsequent entry.

Alternate Entry Procedure

Alternate entry procedure may be used instead of the entry permit if all of the following conditions listed below are "YES":

The ONLY hazard is atmospheric; and

Continuous forced air ventilation ALONE is sufficient to keep the space safe for entry; and

Monitoring and inspection show that other hazardous conditions do not exist; and

Conditions that make it unsafe to remove entrance cover have been eliminated; and

Openings are guarded to protect employees from falls and falling objects

NOTE: WHEN PERMIT-SPACE ENTRY IS REQUIRED TO VERIFY CONDITIONS, THE PERMIT REQUIRED CONFINED SPACE PROGRAM AND ENTRY PERMIT MUST BE USED.

Reclassification of Permit Space to Non-Permit Space

Reclassifying a permit space may be performed if all of the following conditions listed below are "YES":

The permit space poses no actual atmospheric hazards; and

All hazards within the space can be eliminated without entry into the space; and

Employees have been informed or shown the actions to take to eliminate hazards

NOTE: WHEN PERMIT-SPACE ENTRY IS REQUIRED TO VERIFY CONDITIONS, THE PERMIT REQUIRED CONFINED SPACE PROGRAM AND ENTRY PERMIT MUST BE USED.

If hazards arise within or near the reclassified space, remove employees immediately and re-evaluate to determine whether it must be reclassified as a permit required space.

Confined Space Additional Readings Work Sheet

Atmospheric Test Results (Cont.)

Test Results
Time
Oxygen Concentration (19.5% minimum/23.5% maximum)
Combustible Vapor Concentration (10% LEL maximum)
Carbon Monoxide Concentration (35 ppm maximum)
Hydrogen Sulfide Concentration (10 ppm maximum)

Entrant(s) in or out of permit required confined space?

Sign Off

Entrant(s) Name & Signature

Entrant
Add signature

Attendant(s) Name & Signature

Attendant
Add signature

All required precautions have been taken and necessary equipment is provided for entry and work in confined space.

Entry Supervisor(s) Name & Signature

Entry Supervisor
Add signature

The Alternate Entry Procedure/Reclassification Form cannot be used if both sections are required to be completed. If an atmospheric hazards AND any other hazard from the Permit Required Section needs to be removed, then the Confined Space Entry Permit Form must be used.

Alternate Entry

Reclassification

E-MAIL COMPLETED FORM TO THE SAFETY DEPARTMENT