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CONFINED SPACE ENTRY PERMIT
Job Name
Job Number
Type of Confined Space
Alternate Entry Confined Space
Permit Required Confined Space
Location of Confined Space:
Task(s) to be Completed:
Space Description:
Start Date
MM slash DD slash YYYY
Start Time
Hours
:
Minutes
AM
PM
AM/PM
End Date
MM slash DD slash YYYY
End Time
Hours
:
Minutes
AM
PM
AM/PM
Entry Supervisor
Title
Entry Attendant
Authorized Entrants
Add
Remove
HAZARDS INHERENT TO THE SPACE
Outside Space
Heat / Cold
Slips / Falls
Space Access
Atmospheric Lighting
Natural Gas Lines
Biological
Sewer Lines
Entrapment
Water Lines
Engulfment
Electrical
Fire
Configuration
Explosion
Chemical
Other
HAZARDS INTRODUCED INTO THE SPACE
Paints / Sealants / Caulk
Cleaning Chemicals
Solvents
Corrosives
Heat
Grinding
Sanding
Welding / Cutting
Tools that may Spark
Other
Other (describe inherent hazards)
Other (describe introduced hazards)
Acceptable Entry Conditions
Affected Departments and/or Personnel Notified?
N/A
Yes
No
Department that was notified:
Confined Space Perimeter Setup and Secure?
N/A
Yes
No
Atmospheric Testing?
N/A
Yes
No
Pre-Ventilation Testing Results
O2 19.5-23.5%
LEL <10%
CO <25 PPM
H2S <10 PPM
Other <PEL/TLV
Time of Testing
Add
Remove
Post-Ventilation Testing Results
O2 19.5-23.5%
LEL <10%
CO <25 PPM
H2S <10 PPM
Other <PEL/TLV
Time of Testing
Add
Remove
Ongoing Testing Results
O2 19.5-23.5%
LEL <10%
CO <25 PPM
H2S <10 PPM
Other <PEL/TLV
Time of Testing
Add
Remove
Tested By:
Meter ID
Last Calibration Date
Lockout Tagout of Hazardous Energy Sources (Prior to Entry)
N/A
Yes
No
Space Ventilation
Ventilation Equipment Used
Equipment Used
Fan ID
Fan CFM
Other
Add
Remove
Communication Method
Radio
Voice
Visual
Cell
Other
Other Method:
Lighting
N/A
Yes
No
PPE Required
N/A
Yes
No
Hard Hat
Safety Glasses
High Visibility
Gloves
Other
Other PPE
Other Permits Attached (i.e., LOTO Checklist and Hot Work Permit)
N/A
Yes
No
Attachment Upload
Drop files here or
Select files
Max. file size: 100 MB.
Rescue
*When using 3rd party rescue services; provide additional contact information and rescue plan to this permit
Rescue Equipment
N/A
Yes
No
Rescue Equipment Used
Rescue and Emergency Services Available
N/A
Yes
No
Rescue and Emergency Services Used
Equipment List
Ventilation Fan and Venting
Ladder or other Access Equipment
Extension Cord
Tools for the Job
Tripod with Winch and Lifeline/ Harness
Fire Extinguisher
Radio
First Aid Kit
Lighting
Barriers
Gas Meter
Other
Other Equipment
Supervisor Name:
First
Last
Supervisor Signature
Supervisor- I agree the above name and signature are my own
Yes
Attendant Name:
First
Last
Attendant Signature
Attendant - I agree the above name and signature are my own
Yes
Entrant 1 Name:
First
Last
Entrant 1 Signature
Entrant 1 - I agree the above name and signature are my own
Yes
Entrant 2 Name:
First
Last
Entrant 2 Signature
Entrant 2 - I agree the above name and signature are my own
Yes
Entrant 3 Name:
First
Last
Entrant 3 Signature
Entrant 3- I agree the above name and signature are my own
Yes
Entrant 4 Name:
First
Last
Entrant 4 Signature
Entrant 4 - I agree the above name and signature are my own
Yes
Entrant 5 Name:
First
Last
Entrant 5 Signature
Entrant 5 - I agree the above name and signature are my own
Yes
Entrant 6 Name:
First
Last
Entrant 6 Signature
Entrant 6 - I agree the above name and signature are my own
Yes
Entrant 7 Name:
First
Last
Entrant 7 Signature
Entrant 7 - I agree the above name and signature are my own
Yes
Entrant 8 Name:
First
Last
Entrant 8 Signature
Entrant 8 - I agree the above name and signature are my own
Yes
Entrant 9 Name:
First
Last
Entrant 9 Signature
Entrant 9 - I agree the above name and signature are my own
Yes
Entrant 10 Name:
First
Last
Entrant 10 Signature
Entrant 10 - I agree the above name and signature are my own
Yes
Additional Email 1
Send a notification to an additional email
Additional Email 2
Send a notification to an additional email
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