Confined Space Permit

• Audit Title

• Job Number

• Job Name

1.1 Scope

• Effective date and time

  Date

• Expires (date and time)

  Date

• Permit issued to

• Description of work

• Location
  Address

• Specific Location

• Is continuous monitoring required?

  No

  Yes
Instrument

• Serial Number

• Most Recent Calibration

  Date

• Field (fresh air) Calibration

  Pass

  Fail

• Sensor reading for failure check

2.1 Hazards (check all that apply)

• Flammable Atmosphere

• Corrosive

• Reactive

• Toxic

• Temperature (>100 degrees F or < 50 degrees F)

• Engulfment

• Other Hazards

• Describe other hazard(s)

3.1 Preparation

• Equipment /piping depressurized and vented

• Equipment / piping blinded, blanked or disaligned

• Power (forced air) ventilation

• Electric, hydraulic, pneumatic and mechanical energy sources shut-off and locked out (zero energy state)

• Vessel /space steamed, cleaned or washed

4.1 Entry Type

• Horizontal

• Vertical

5.1 Atmospheric Testing

• Air Sample(s)

Air sample

• Time

  Date

• Oxygen Level (Action Levels: 19.5-23%)

• %LEL (if > 10% evaluate for toxicity)

• Hydrogen Sulfide (H2S) (PPM)

• Carbon Monoxide (CO2)

• Temperature

• Atmospheric Check after isolation or forced air ventilation

Check after Isolation or ventilation

• Select date

  Date

• Oxygen Level (Action Levels: 19.5-23%)

• %LEL (if > 10% evaluate for toxicity)

• Hydrogen Sulfide (H2S) (PPM)

• Carbon Monoxide (CO2)

• Temperature

6.1 Protective Equipment

6.2 Protective Equipment (Operational)

• Warning signs, barricades

• Barricade tape, cones

• Ventilation fan or blower

• Fire equipment in place

• GFCI'S in place

• Lighting (hazardous location rated)

• Grounding and/or bonding

• Ladder

• Other

• Describe

6.3 Personal Protective Equipment

• Airline respirator

• SCBA

• Other respirator

• Gloves

• Rain gear

• Boots

• Hearing protection

• Safety glasses

• Fall protection/arresting equipment

• Chemical splash goggles

• Other

• Describe

7.1 Rescue Procedures and Equipment

• Rescue plan complete

• Emergency Number

• Location of phone or radio

7.2 Rescue Equipment On Site

• Full body harness / lifeline

• Rescue winch

• Tripod

• Other

7.3 CSE Communication

• Cell phone

• Radio

• Rope signals (OATH)

• Sound

• Verbal

• Visual hand signals

• Other

• Emergency assembly area

• Potential emergency situations

• Designated Rescue Team

• Actions to be taken

8.1 Confined Space Entrants

• We (I) have reviewed the potential emergency situations and actions to be taken. We (I) are familiar with all rescue equipment and communication methods. See entrant employee roster section of the permit for additional signatures. I have been formally trained in CSE.

• Confined Space Entrants

Confined Space Entrant

• Name and Signature (ENTRANT MUST SIGN)

  Sign

9.1 Confined Space Attendant(s)

• I have checked all rescue and communication equipment and reviewed all emergency actions to be taken with authorized entrants. I have been formally trained in CSE.

Confined Space Attendant

• Name and Signature (ATTENDANT MUST SIGN)

  Sign

10.1 Confined Space Entry Supervisor

• I have complete pr properly evaluated all portions of this permit and verified that acceptable entry conditions exist. All personnel have reviewed the conditions of the permit and are adequately trained to perform this task. I have been formally trained in CSE.

Confined Space Entry Supervisor

• Name and Signature (SUPERVISOR MUST SIGN)

  Sign

• Date and time

  Date

11.1 Authorized Entrant Roster

• Date

  Date

We (I) have reviewed the potential emergency situations and actions to be taken. We (I) are familiar with all rescue equipment, procedures and communication methods.

• Entrant Name and Intials

Entrant Name

• Add signature

  Sign

• Date and time IN

  Date

• Date and time OUT

  Date

12.1 Periodic Atmospheric Tests REQUIRED

Atmospheric Test

• Time

  Date

• Oxygen % (O2)

• % LEL

• H2S

• CO

• Initials

  Sign

13.1 Permit Cancellation

• Job completed, high LEL, etc. Provide a brief description