Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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SPACE / EQUIPMENT IDENTIFIER:
STEP ONE: (If all three are checked, it is a Permitted - Confined Space)
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Is the space large enough for an employee to bodily enter and perform work?
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Are there limited means of entry or exit?
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Is it NOT designated for continuous occupancy?
STEP TWO: (If ANY one hazard is present, it's a "PERMIT-REQUIRED" Confined Space)
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Is there a potential for an atmospheric hazard?
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Is there a potential for an engulfment hazard?
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Is the space so configured that it poses a hazard?
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Is there any other recognized hazard (not listed here)? If Yes, list.
ATMOSPHERIC HAZARDS ......................REQUIRED PPE and/or Equipment.......................RESCUE/ENTRY PROCEDURES
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Oxygen Deficiency (<19%)?
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Flammable Materials?
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Toxic Substances?
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OTHER Hazard? If Yes, List.
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Monitoring Equipment Required? If Yes, List.
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Ventilating Equipment Required? If Yes, List.
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Communication Equipment Required? If Yes, List.
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Is a Rescue Team on site?
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Is an Off-Site Rescue Team on Standby? If Yes, list who & where.
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Is a retrieval system required and/or available?
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Are wristlets required and/or available?
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Is a Tripod & safety harness required and/or available?
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Are Communication Devices Required and/or available?
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Is an Emergency Call list available?
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OTHER requirement not identified? If Yes, List.
ENGULFMENT HAZARDS ......................REQUIRED PPE and/or Equipment.......................RESCUE/ENTRY PROCEDURES
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Is there a potential for Flowable Materials?
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Are Hard Hats required and/or need to be available?
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Is Eye Protection required and/or needs to be available? If REQUIRED, list type(s).
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Is Hearing Protection required and/ or needs to be available? If REQUIRED, list type(s).
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Are Gloves required and/or needs to be available? IF REQUIRED, list type(s).
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Is special Safety Footwear required and/or needs to be available? If REQUIRED, list type(s).
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Is Respiratory Protection required and/or needs to be available? If REQUIRED, list type(s).
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Is Special Clothing required and/or needs to be available? If REQUIRED, list type(s).
CONFIGURATION HAZARDS ......................REQUIRED PPE and/or Equipment.......................RESCUE/ENTRY PROCEDURES
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Are there downward sloping floors?
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Are there inwardly converging walls?
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Is Special Lighting required and/or needs to available? If REQUIRED, list type(s).
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Are Explosion-Proof or Spark-Proof Tools required and/or needs to be available? If REQUIRED, list type(s).
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Are GFCI's required?
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Is Special Electrical Personal Protective Equipment required and/or needs to be available? If REQUIRED, list type(s).
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Are Ladders required and/or needs to be available? If REQUIRED, list type(s).
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Are MSDS (Material Safety Data Sheets) required and/or needs to available?
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OTHER requirement NOT listed:
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Is cleaning or purging required?
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Is Ventilation required and/or needs to be available? If REQUIRED, list type(s).
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Is Isolation and/or Block & Bleed required?
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Is Testing and/or Monitoring - Oxygen (19.5 - 23.5%) required?
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Is Testing and/or Monitoring - Flammable (<10% LEL) required?
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Is Testing and/or Monitoring - Toxics (<PEL) required?
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Review of applicable MSDS (Material Safety Data Sheets) required?
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Is a HOT WORK PERMIT required?
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OTHER requirement NOT listed?
OTHER HAZARDS ............................REQUIRED PPE and/or Equipment............................RESCUE/ENTRY PROCEDURES
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Are there Mechanical Hazards? If Yes, list.
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Are there Electrical Hazards? If Yes, list.
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Are there Wet/Slippery Conditions? If Yes, Explain.
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Are there Heat and/or Cold Safety Concerns? If Yes, Explain.
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Is there a potential for Reduced Visibility? If Yes, Explain.
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Is there a Noise Concern? If Yes, Explain.
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OTHER Hazardous Concern NOT listed?
COMMENTS / ADDITIONAL INFORMATION
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Photograph of Space #1 OPTIONAL
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Photograph of Space #2 OPTIONAL
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Photograph of Space #3 OPTIONAL
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Photograph of Space #4 OPTIONAL
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SPECIAL REQUIREMENTS FOR NON-PERMITTED SPACES: