Confined Space Permit Request.pdf

This is a Confined Space Entry Permit form (Revised June 2015) used to authorize and document safe entry into confined spaces for work activities.

The permit establishes mandatory safety procedures and requirements for confined space entry operations. Pages 1 and 2 are completed by the site supervisor and include fields for job site identification, work description, equipment specifications, and identification of authorized personnel (entry supervisors, entrants, and attendants). The form requires documentation of required equipment including communication methods, personal protective equipment (PPE), traffic controls, and hot work permits. Critical pre-entry requirements include: verification that all equipment has been tested and inspected, confirmation that entrants, attendants, and supervisors have current confined space training, identification of hazards and team briefing, and notification of the rescue team prior to entry. The form mandates atmospheric testing with acceptable entry conditions of 19.5%-23.5% oxygen, combustible gas below 10% LEL, and carbon monoxide 0-25 PPM, with documentation of calibration dates and initial readings. Pages 3 and 4, completed by the entry supervisor, validate the permit's 8-hour validity period and track completion of 13 specific safety requirements (lockout/tagout, ventilation, secure area, breathing apparatus, safety personnel, harness, emergency equipment, lifelines, fire extinguishers, lighting, protective clothing, respirators, and burning/welding permits). The form requires continuous atmospheric monitoring every 2 hours throughout the job, signature authorization from both site and entry supervisors, and documentation of work completion with specific contact phone numbers for emergency services, hospital, safety personnel, and site security.