Confined Space Entry Permit

• Client / Site

• Confined Space to be Entered

• Purpose of Entry

• Entry Supervisor

• Conducted on

  Date

• Permit Expiration

  Date

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

  Yes

  No

  N/A

• Flammable Vapors (Greater than 10% LEL)

  Yes

  No

  N/A

• Toxins (Greater than specified or PEL)

  Yes

  No

  N/A

• Mechanical

  Yes

  No

  N/A

• Electrical

  Yes

  No

  N/A

• Corrosive or Skin Irritant

  Yes

  No

  N/A

• Engulfment

  Yes

  No

  N/A

• Other - specify

  Yes

  No

  N/A

Preparation

• Notification of Affected Personnel

  Yes

  No

  N/A

• Isolation

  Yes

  No

  N/A

• Lockout/Tagout

  Yes

  No

  N/A

• Cleaning/Purging

  Yes

  No

  N/A

• Ventilation (30 minutes minimum)

  Yes

  No

  N/A

• Emergency Responders Available

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Third Person Within Radio Calling Distance

  Yes

  No

  N/A

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

• The ONLY hazard is atmospheric; and

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Openings are guarded to protect employees from falls and falling objects

  Yes

  No

  N/A

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

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

• Atmospheric Test Results (Cont.)

Test Results

• Time

  Date

• 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?

  In

  Out

• Entrant(s) Name & Signature

Entrant

• Add signature

  Sign

• Attendant(s) Name & Signature

Attendant

• Add signature

  Sign

• 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

  Sign

• 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