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Confined Space Entry Permit

Archive Document – DO NOT DISCARD

General Information

* Permit is valid for one shift only

Required Signatures

Description

Name (print)

Signature

Training Completed

Date
DPR Management
DPR EHS
Entry Supervisor
Qualified Attendant
Qualified Entrant 1
Qualified Entrant 2
Qualified Entrant 3

Air monitoring Log

Gas Monitor (Model 0): Calibration Date:
Date Time Reading and Location Tester Name
Top Middle Bottom
02 LEL CO H2S 02 LEL CO H2S 02 LEL CO H2S
Chemical Action Levels (For Additional Chemicals Refer to Federal/State Regulations)
Percent Oxygen 19.5% or 23.5% Hydrocyanic Acid 10 ppm
Percent LEL Any % over 10 Sulfur Dioxide or H2S 5 ppm
Hydrocarbon/Volatile 5 ppm Ammonia 25 ppm
Carbon Monoxide 50 ppm (Fed) 25ppm (CA) Dust Meet or Exceed LEL

Hazards of the Permit Space

Hazard Description Yes No N/A Hazard Description Yes No N/A
Lack of Oxygen Temperature
Combustible Gases Engulfment
Combustible Vapors Entrapment
Combustible Dusts Pressure Systems
Toxic Gases Welding/Burning/Open Flame
Toxic Vapors Dehydration/Heat Exhaustion
Chemical Contact Falls
Electrical Hazards Unknown or Spilled Liquids
Mechanical Exposure Other

Methods for Abating Hazards

Purge/Flush & Vent Buddy System Goggles/Faceshield
Mechanical Ventilation Evacuation Alarm Gloves
Lockout/Tagout Lifelines & Escape Harnesses Hearing Protection
lnerting Emergency Egress Procedure Protective Clothing
Blanking, Blocking, Bleeding Tripod Escape Unit Other:
External Barricades Fire Extinguishers    
Signage Respirator    
Shields/Barriers Supplied Air/SCBA    
Lighting Fall Protection    
Resuscitator Safety Glasses