PERMIT EXEMPT SPACE ENTRY CERTIFICATE.pdf

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Attached to
H345--Backflow Prevention Device Testing SDVOSB Set Aside Amendment 00001 Federal contract opportunity
Solicitation number
36C24123Q0699
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 1

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Other files attached to H345--Backflow Prevention Device Testing SDVOSB Set Aside Amendment 00001, newest first.
File Type Posted
CONFINED SPACE PERMIT.pdf PDF
36C24123Q0699_1.docx DOCX document
BFP Test Report Example.pdf PDF
S02_Attachment 4_VARR 852.219-75_Certificate of Compliance.pdf PDF
S02_Attachment 2_Price Schedule.xlsx XLSX spreadsheet
S02_Attachment 1_PWS_Backflow Testing.docx DOCX document
P07_Wage Determination_2015-4095 (Rev-24).pdf PDF
S02_Attachment 3_Past Performance Worksheet.xlsx XLSX spreadsheet
36C24123Q0699.docx DOCX document

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PERMIT EXEMPT SPACE ENTRY CERTIFICATE

(Complete All Items)

LOCATION OF SPACE: _________________________________________________________

DATE AND TIME OF ENTRY: ___________________________________________________

NAME OF ENTRY SUPERVISOR (Print) __________________________________________

NOTE: An entry supervisor also may serve as an attendant or as an authorized entrant, as long as that person is trained and equipped as required by this section for each role he or she fills. Also, the duties of entry supervisor may be passed from one individual to another during the course of an entry operation.

NAME OF THE AUTHORIZED ENTRANT(S):

NAME OF ATTENDANT(S)

LOCATION OF THE EXEMPT SPACE:

DESCRIPTION OF MECHANICAL VENTILATION SYSTEM USED:

(If fan is used, fan must be OSHA certified fan for confined space)

DESCRIPTION OF PHYSICAL BARRIER(S) TO PREVENT UNAUTHORIZED ENTRY INTO

SPACE

ENERGY SOURCES LOCKED OUT (Attach copy of each completed Lockout procedure)

* Initial Pre-Entry Air Test Result: (Record Time of Testing)

Date Time CO H2S O2 LEL (lower explosive limit)

* Required to be taken prior to entry into the space.

SAFE LEVELS: Oxygen between 19.5% – 23.5%: CO < 35 ppm: H2S 10 ppm: LEL < 10%

Additional Re-Entry Air Test Results: Note: Atmospheric re-testing is required each time the space is re-entered. Use back of form is more testing is required.

Date Time CO H2S O2 LEL (lower explosive limit)

DATE AND TIME OF COMPLETION OF OCCUPANCY OF THE SPACE

SIGNATURE OF ENTRY SUPERVISOR:

NOTE: Exempt Space Entry Certificate must be returned to the Safety Office upon completion of occupancy of the space.

Complete All Items:
DATE AND TIME OF ENTRY:
NAME OF ENTRY SUPERVISOR Print:
NAME OF THE AUTHORIZED ENTRANTS 1:
NAME OF THE AUTHORIZED ENTRANTS 2:
NAME OF THE AUTHORIZED ENTRANTS 3:
1:
2:
3:
NAME OF ATTENDANTS 1:
NAME OF ATTENDANTS 2:
NAME OF ATTENDANTS 3:
1_2:
2_2:
3_2:
If fan is used fan must be OSHA certified fan for confined space 1:
If fan is used fan must be OSHA certified fan for confined space 2:
SPACE 1:
SPACE 2:
ENERGY SOURCES LOCKED OUT Attach copy of each completed Lockout procedure 1:
ENERGY SOURCES LOCKED OUT Attach copy of each completed Lockout procedure 2:
Date:
Time:
CO:
H2S:
O2:
undefined:
Date 1:
Date 2:
Date 3:
Date 4:
Date 5:
Time 1:
Time 2:
Time 3:
Time 4:
Time 5:
CO 1:
CO 2:
CO 3:
CO 4:
CO 5:
H2S 1:
H2S 2:
H2S 3:
H2S 4:
H2S 5:
O2 1:
O2 2:
O2 3:
O2 4:
O2 5:
1_3:
2_3:
3_3:
4:
5:
DATE AND TIME OF COMPLETION OF OCCUPANCY OF THE SPACE:
undefined_2:

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