Inglett & Stubbs Confined Space Entry Permit

• Document No.

This permit shall remain on site until the job is complete or a new permit issued. Expired permits must be sent to the Safety Director. This permit is void if conditions change within the space. Evacuate the space and do not re-enter until conditions are evaluated and a new permit issued.

• Jobsite/Number

• Date and Time issued

  Date

• Prepared by

Equipment to be worked on:

Stand by personnel:

Personnel

Date and time expires:

• Select date

  Date

Job Supervisor

Work to be performed:

Atmospheric Checks:

• Time

  Date

• Oxygen %

• Explosives % L.F.M.

• H2S PPM

• Carbon Monoxide PPM

• Tester's Signature

  Sign

Source Isolation (No Entry):

• Pumps or lines blinded, disconnected, or blocked:

  Yes

  No

  N/A

Ventilation modification:

• Mechanical

  Yes

  No

  N/A

• Natural Ventilation Only

  Yes

  No

  N/A

Atmospheric check after isolation and ventilation:

• Oxygen % >19.5%

• Explosive % L.F.M. <10%

• H2S PPM <10PPM H2S

• Carbon Monoxide PPM

• Time

  Date

• Tester's Signature

  Sign

Communication procedures:

Rescue procedures:

• Entry standby and backup persons successfully completed required training?

  Yes

  No

  N/A

• Is it current?

  Yes

  No

  N/A

Equipment:

• Direct reading gas monitor tested?

  Yes

  No

  N/A

• Safety harnesses and lifelines for entry and standby persons:

  Yes

  No

  N/A

• Hoisting equipment:

  Yes

  No

  N/A

• Powered communications:

  Yes

  No

  N/A

• SCBA's for entry and standby persons:

  Yes

  No

  N/A

• Protective clothing:

  Yes

  No

  N/A

• All electric equipment listed: Class I, Division I, Group D, and non-sparking tools

  Yes

  No

  N/A

Periodic atmospheric tests:

Periodic Atmospheric Test

• Oxygen %

• Time

  Date

• Explosive %

• Time

  Date

• H2S PPM

• Time

  Date

• Carbon Monoxide PPM

• Time

  Date

We have reviewed the work authorized by this permit and the information contained here. Written instructions and safety procedures have been received and are understood. Entry cannot be approved if any squares are marked in the "NO" column. This permit not valid unless all appropriate items are completed.

• Permit prepared by:

  Sign

This permit is to be kept at the job site. Return this job site copy to the Foreman/General Foreman following job completion.

Entrants

Entrants

• Time in

  Date

• Entrant

  Sign

• Time out

  Date

• Entrant

  Sign