Energis Confined Space Entry Permit

• Location of Space

• Point of Access

• Reason for Entry

• Duration of Entry

• Conducted on

  Date

• Entrants (list all employees entering the confined space):

• Attendant:

• Supervisor:

Hazards Identified

• Identify Potential Hazards within the Confined Space

  Select Access / Egress Bacterial Chemical Exposure Electrical Engulfment Entrapment Gas Lighting Immediately Dangerous to Life or Health - IDLH Mechanical Noise Oxygen Protruding Object(s) Slip / Trip / Fall Space Steam Temperature Other No Major Hazards Identified

  • Access / Egress
  • Bacterial
  • Chemical Exposure
  • Electrical
  • Engulfment
  • Entrapment
  • Gas
  • Lighting
  • Immediately Dangerous to Life or Health - IDLH
  • Mechanical
  • Noise
  • Oxygen
  • Protruding Object(s)
  • Slip / Trip / Fall
  • Space
  • Steam
  • Temperature
  • Other
  • No Major Hazards Identified

• Oxygen Hazard Present

  Select Oxygen Enriched Oxygen Deficient

  • Oxygen Enriched
  • Oxygen Deficient

• Gas Hazard Present

  Select Toxic Gas Combustible Gas

  • Toxic Gas
  • Combustible Gas

• Space Hazard Present

  Select Horizontal Space Vertical Space Limited Space

  • Horizontal Space
  • Vertical Space
  • Limited Space

• Temperature Hazard Identified

  Select Hot Working Conditions Cold Working Conditions

  • Hot Working Conditions
  • Cold Working Conditions

• IDHL Hazard Present

  Select Hazardous condition that poses a threat to life Hazard causes irreversible adverse health effects Hazard interferes with an individual's ability to escape unaided from a permit space Hazard has concentrations so high that they present immediate risk of injury, sickness, or death to an exposed worker

  • Hazardous condition that poses a threat to life
  • Hazard causes irreversible adverse health effects
  • Hazard interferes with an individual's ability to escape unaided from a permit space
  • Hazard has concentrations so high that they present immediate risk of injury, sickness, or death to an exposed worker

• Describe hazardous condition that poses threat to life.

• Describe hazard that causes irreversible adverse health effects.

• Describe hazard that interferes with unaided escape from permit space.

• Describe type of high concentrations.

• Other Hazard Identified

Minimal Required PPE

• Identify Minimal Required PPE for Confined Space Entry

  Select Respirator Protective Clothing Hearing Protection Foot Protection Hand Protection Head Protection Eye Protection Face Shield Fall Equipment Other

  • Respirator
  • Protective Clothing
  • Hearing Protection
  • Foot Protection
  • Hand Protection
  • Head Protection
  • Eye Protection
  • Face Shield
  • Fall Equipment
  • Other

• Identify Other required PPE for confined space entry

Confined Space Entry Requirements

• Identify Confined Space Entry Requirements

  Select Pre-Entry & Rescue Briefing Air Monitor Ventilation External Barricade / Barrier Tape How Work Permit & Procedures Lighting Flush/Purge/Drain/Clean Electric Precautions Rescue Equipment Communication Fall Protection Lockout/Tagout Procedures Traffic Control Procedures Other

  • Pre-Entry & Rescue Briefing
  • Air Monitor
  • Ventilation
  • External Barricade / Barrier Tape
  • How Work Permit & Procedures
  • Lighting
  • Flush/Purge/Drain/Clean
  • Electric Precautions
  • Rescue Equipment
  • Communication
  • Fall Protection
  • Lockout/Tagout Procedures
  • Traffic Control Procedures
  • Other

• Rescue Equipment Required

  Select Tripod Hoist Davit Body Harness Lifeline Other

  • Tripod
  • Hoist
  • Davit
  • Body Harness
  • Lifeline
  • Other

• Describe Other Rescue Equipment Required

• Type of Communication Required

  Verbal

  Signals

  Radio

  Phone

  Other

• Describe Other Communication Required

• Fall Protection System Required

  Fall Restraint (200 lb force restraint)

  Fall Protection (5000 lb force anchor)

Emergency Response Team Notification

• For each entry into permit required confined spaces, ensure you have a contact for an emergency response team.

• Rescue Team

• Rescue Team Phone #

• Provide location, phone # of person on site, entry start time, and estimated duration. Notify again once entry is completed.

Ventilation

• Employees shall not enter a confined space if a hazardous atmosphere exists. If at any time, the LEL exceeds the Permissible Levels, the employee shall immediately evacuate the confined space. Forced air ventilation is used to maintain oxygen at a safe level and prevent a hazardous concentration of flammable gasses and vapors. The air supply for forced air should be from a clean source and should not increase hazards. (i.e. vehicle exhaust)

• Air monitor equipment tested and calibrated before use?

  Yes

  No

  N/A

• Signature

  Sign

• Meter Model & Serial #

Atmospheric Readings Before Entry

• Ensure that all areas of the space are tested, including entrance and all applicable work spaces. Enter results in the areas below...

• Date/Time

  Date

• Location within the confined space

• Oxygen (O2) (acceptable range 19.5% - 23.5%):

• Explosive LEL% (acceptable range < 10%):

• Hydrogen Sulfide (H2S) (acceptable range < 10 ppm):

• Carbon Monoxide (CO) (acceptable range < 35 ppm):

• Are all readings acceptable making the space safe to enter?

  Safe

  At Risk

  N/A

• Signature

  Sign

Atmospheric Readings During Entry

• Atmospheric conditions should be continuously monitored while entrant(s) are within the confined space. Conditions should be documented every 30 minutes until the entrant(s) have exited the confined space.

• Atmospheric Readings During Entry (Every 30 Minutes - Max 1 Hour Intervals)

Record of Air Monitoring Results

• Date/Time

  Date

• Location within the confined space

• Oxygen (O2) (acceptable range 19.5% - 23.5%):

• Explosive LEL% (acceptable range < 10%):

• Hydrogen Sulfide (H2S) (acceptable range < 10 ppm):

• Carbon Monoxide (CO) (acceptable range < 35 ppm):

• Are all readings acceptable making the space safe to continue working?

  Safe

  At Risk

  N/A

• Signature

  Sign

Closing Permit

• I (authorized employee) verify the above Permit is accurately completed. Written instructions and safety procedures have been received and understood by team members.

• Entry Permit Completed By (Name & Title)

• Entrant signature (all entrants must sign):

Signature

• Entrant Signature

  Sign

• Attendant Signature

  Sign

• Entry Supervisor Signature

  Sign

• Permit Expires

  Date