Confined Space Entry Permit

• Company

• Job Site
  Address

• Date & Time Issued

  Date

• Date & Time Expires

  Date

• Purpose of Entry

• Permit Number

Emergency

• Rescue Number

• Gas Coordinator Number

• Emergency Services Number

• Oxygen Deficiency (>19.5%)

• Toxic Gases or Vapors > PEL

• Engulfment or Entrapment

  Yes

  No

  N/A

• Which one?

  Yes

  No

  N/A

• Electrical Hazards

• Flammable Hazards (gasses, vapors, high oxygen)

• Heat or Cold

  Yes

  No

  N/A

• Which one?

  Yes

  No

  N/A

• Hazardous Configuration

• Rotating or Moving Equipment

• Chemical Hazards

• Other

Required Entry Equipment

• Respirator

• Coveralls

• Hearing Protection

• Explosive Proof Lighting

• Fire Extinguishers

• Harnesses

• Emergency Escape Equipment

• Resuscitator - Inhalator

• Emergency Escape Respirator

• Other

Communication

• Line of Sight

• Radios

• Other

• Additional Notes

• Entrants

  Sign

• Attendants

  Sign

• Supervisors

  Sign

Written Rescue Plan Posted

• Employee Rescue

• Employee Non Entry Rescue

• Outside Rescue - Contact #

• Acceptable Entry Conditions

• Notify affected employees of work

• Isolate hazardous energy

• Apply locks and tags

• Verify isolation

• Secure area with posts and flags

• Clean, drain and purge space

• Establish required ventilation

• Review hazards and work procedure

• Notify available emergency team

• Atmospheric test satisfactory

• Additional permits obtained

• Required PPE worn

• Communication plan works

• Other

Atmospheric Testing - Test Will Be Done Before Entry

• Continuous Monitoring?

  Yes

  No

  N/A

• Why not?

  Yes

  No

  N/A

• Test Frequency

• Tester Name

• Tester ID

• Tester Name

• Tester ID

Testing