USSW Confined Space Entry Permit V1

• Site Location

• Beginning Permit Date and Time (AM/PM)

• Date and Time Permit Expires(AM/PM)

• Hazardous Area?

  Yes

  No

  N/A

• Permit Space Description

• Purpose of Entry ?

• Supervisor Authorizing Entry?

Requirement

• First Aid /CPR Training Date and Time

• Secure Area (Isolate) Date and Time

• Lockout/ Tagout Date and Time

• Purge, Flush, Ventilate Date and Time

• Standby Safety Person(s)

• Current Training

• Breathing App. (SCBA) Date and Time

• Rescue Equipment

• Harness w "D" Ring Date and Time

• Lifelines Date and Time

• Personal Protection Date and Time

• Fire Extinguishers Date and Time

• Lighting (Exp. Proof)

  Yes

  No

  N/A

Continuous Monitoring (To be taken at least every 2 hours)

• Percent of Oxygen ( 19.5% - 23.5% Permissible ) Initial reading, time and %, and monitoring results

• Lower Flammable Limit ( under 10% Permissible) Initial reading, time and %, and monitoring results

• Carbon Monoxide (Under 25ppm Permissible) Initial reading, time ppm and monitoring results

• Hydrogen Sulfide ( Under 10 ppm Permissible Initial reading, time and monitoring results

  Yes

  No

  N/A

8 hour Time weighted average(TWA) Employee(s) can work in area at or below the designated concentration for 8 HR w/o PPE

• Hazard to be encountered

• Control Measures

• Air monitoring personel

• Instrument(s) make , model/type and serial number

• Authorized Entrant(s) Roster

• Name of standby person(s)/attendant(s) *standby person is required for all confined space work

• Describe communication procedure

• Describe rescue procedure

• Rescue contact #

• Ambulance contact #

• Fire contact #

• Air monitor contact #

• Safety contact #

Additional information

• Put any other pertinent information

• All current conditions satified?

  Yes

  No

  N/A

• Current Entry Supervisor Name and Phone #

• Permit canceled by Name , date and time

• Yes

  No

  N/A