Confined Space Page 2 HBI – Confined Space Page 2 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 RemoveHAZARDS 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 ConditionsAffected 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 ResultsO2 19.5-23.5%LEL <10%CO <25 PPMH2S <10 PPMOther <PEL/TLVTime of Testing Add RemovePost-Ventilation Testing ResultsO2 19.5-23.5%LEL <10%CO <25 PPMH2S <10 PPMOther <PEL/TLVTime of Testing Add RemoveOngoing Testing ResultsO2 19.5-23.5%LEL <10%CO <25 PPMH2S <10 PPMOther <PEL/TLVTime of Testing Add RemoveTested By: Meter ID Last Calibration Date Lockout Tagout of Hazardous Energy Sources (Prior to Entry) N/A Yes No Space VentilationVentilation Equipment UsedEquipment UsedFan IDFan CFMOther Add RemoveCommunication 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 permitRescue 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 SignatureSupervisor- I agree the above name and signature are my own Yes Attendant Name: First Last Attendant SignatureAttendant – I agree the above name and signature are my own Yes Entrant 1 Name: First Last Entrant 1 SignatureEntrant 1 – I agree the above name and signature are my own Yes Entrant 2 Name: First Last Entrant 2 SignatureEntrant 2 – I agree the above name and signature are my own Yes Entrant 3 Name: First Last Entrant 3 SignatureEntrant 3- I agree the above name and signature are my own Yes Entrant 4 Name: First Last Entrant 4 SignatureEntrant 4 – I agree the above name and signature are my own Yes Entrant 5 Name: First Last Entrant 5 SignatureEntrant 5 – I agree the above name and signature are my own Yes Entrant 6 Name: First Last Entrant 6 SignatureEntrant 6 – I agree the above name and signature are my own Yes Entrant 7 Name: First Last Entrant 7 SignatureEntrant 7 – I agree the above name and signature are my own Yes Entrant 8 Name: First Last Entrant 8 SignatureEntrant 8 – I agree the above name and signature are my own Yes Entrant 9 Name: First Last Entrant 9 SignatureEntrant 9 – I agree the above name and signature are my own Yes Entrant 10 Name: First Last Entrant 10 SignatureEntrant 10 – I agree the above name and signature are my own Yes Additional Email 1 Send a notification to an additional emailAdditional Email 2 Send a notification to an additional email
