36C25618Q0303-004.pdf

ATTACHMENT J

CONFINED SPACE ENTRY PERMIT

Date and Time Issued: ________________________________

Date and Time Expires: _______________________________

Job site/Space I.D.: __________________________________

Job Supervisor: ________________________________________________

Equipment to be worked on: _______________________________________

Work to be performed: ___________________________________________

Entrants Name(s)

Stand-by personnel:

Tester’s signature:

1. Atmospheric Checks:

(a) Time _____________

(b) Oxygen ___________ %

(c) Explosive _________ % L.E.L.

(d) Toxic Gas _____________ PPM

(e) H(2)S_____________

2. Source isolation (No Entry): N/A Yes No

3. Ventilation Modification: N/A Yes No

4. Pumps or lines blinded, N/A Yes No

5. Mechanical disconnected or blocked N/A Yes No

6. Natural Ventilation only N/A Yes No

7. Atmospheric check after isolation and ventilation:

(a) Oxygen ___________ % > 19.5 % <23..5%

(b) Explosive ___________ % L.E.L < 10 %

(c) Toxic ___________ PPM < 10 PPM

(d) H(2)S ___________

(e) Time ___________

Tester’s signature:

8. Communication procedures:

9. Rescue procedures:

8. Entry, standby and back up persons: Yes No

(a) Successfully completed required training? Yes No

(b) Is it current? Yes No

9. Equipment: N/A Yes No

(a) Direct reading gas monitor—tested - N/A Yes No

(b) Safety harnesses and lifelines for entry and standby persons N/A Yes No

(c) Hoisting equipment N/A Yes No

(d) Powered communications N/A Yes No

(e) SABA or SCBA for entry and standby Persons N/A Yes No

(f) Protective Clothing N/A Yes No

(g) All electric equipment listed Class I, Division I, Group D, and non-sparking tools N/A Yes No

10. Periodic atmospheric tests:

Time ______ Oxygen ______% Explosive ______ Toxic ______ Time ______ Oxygen ______% Explosive ______ Toxic ______ Time ______ Oxygen _______% Explosive ______ Toxic ______ Time ______ Oxygen _______% Explosive ______ Toxic ______ Time ______ Oxygen _______% Explosive ______ Toxic ______ Time ______ Oxygen _______% Explosive ______ Toxic ______

We have reviewed the work authorized by this permit and the information contained herein. Written instructions and safety procedures have been received and are understood. Entry cannot be approved if any squares are marked in the “No” column. This permit is not valid unless all appropriate items are completed.

Permit Prepared By: (Supervisor)

Approved By: (Unit Supervisor)

Reviewed By: (Operations Personnel)

(printed name) (signature)

This permit is to be kept at job site. Return job site copy to Safety Office following job completion.

C. CONFINED SPACE ENTRY PERMIT

(See Appendix D-2 in 1910.146 for prior table layout. (Page 313 of green book)

PERMIT VALID FOR 8 HOURS ONLY. ALL COPIES OF PERMIT WILL REMAIN

AT JOB SITE UNTIL JOB IS COMPLETED

Date: ____________

Site Location and Description:

Purpose of Entry:

Supervisor(s) in charge of crews

Type of Crew Phone

Communication Procedures:

Rescue Procedures (Phone Numbers at Bottom)

BOLD DENOTES MINIMUN REQUIREMENTS TO BE COMPLETED AND

REVIEWED PRIOR TO ENTRY

REQUIREMENTS COMPLETED DATE TIME N/A

Lock Out/De-energizer/Try-out ______ ______ _____ Line(s) Broken-Capped-Blanked ______ ______ _____ Purge-Flush and Vent ______ ______ _____ Ventilation ______ ______ _____ Secure Area (Post and Flag) ______ ______ _____ Breathing Apparatus ______ ______ _____ Resuscitator – Inhalator ______ ______ _____ Standby Safety Personnel ______ ______ _____ Full Body Harness w/”D” ring ______ ______ _____ Emergency Escape Retrieval Equipment ______ ______ _____ Lifelines ______ ______ _____ Fire Extinguishers ______ ______ _____ Lightning (Explosive Proof) ______ ______ _____ Protective Clothing ______ ______ _____ Respirator(s) (Air Purifying) ______ ______ _____ Burning and Welding Permit ______ ______ _____ Note: Items that do not apply enter N/A in the blank.

**RECORD CONTINUOUS MONITORING RESULTS EVERY 2 HOURS OF THE

ITEMS BELOW: **

CONTINUOUS MONITORING** Permissible TEST(S) TO BE TAKEN Entry Level

PERCENT OF OXYGEN 19.5% to 23.5% LOWER FLAMMABLE LIMIT Under 10%

CARBON MONOXIDE +35 PPM

Aromatic Hydrocarbon + 1 PPM * 5PPM Hydrogen Cyanide (Skin) * 4PPM Hydrogen Sulfide +10 PPM *15PPM Sulfur Dioxide + 2 PPM * 5PPM Ammonia *35PPM

*Short-term exposure limit: Employee can work in the area up to 15 minutes.

+8 hr. Time-Weighted Avg.: Employee can work in area 8 hrs. (longer with appropriate respiratory protection).

REMARKS:

GAS TESTER NAME & CHECK # ______________________________

INSTRUMENT(S) USED ______________________________

MODEL &/OR TYPE ______________________________

SERIAL &/R UNIT # ______________________________

SAFETY STANDBY PERSON IS REQUIRED FOR ALL CONFINED SPACE

WORK

SAFETY STANDBY CONFINED SPACE

CONFINED SPACE

PERSON(S) CHECK #

ENTRANT(S) CHECK #

ENTRANT(S) CHECK #

SUPERVISOR AUTHORIZING ____________________________________

ALL CONDITIONS SATISFIED ____________________________________

DEPARTMENT/PHONE __________________________________________

PHONE # FOR AMBULANCE _____________________________________

PHONE # FOR FIRE DEPARTMENT ________________________________

PHONE # FOR RESCUE _________________________________________

PHONE # FOR GAS COMPANY ____________________________________

IX. REFERENCES:

29 CFR 1910.146, Permit Required Confined Space.

Subpart Z (Toxic and Hazardous Substances), 29 CFR 1910.100.

Respiratory Protection, 29 CFR 1910.134.

American National Standard Institute (ANSI) Standard 2117.1 – 1989