A21 - Enclosure C - CSE-Permit (with RFQ).pdf

Appendix D - 1 Confined Space Entry Permit Date & Time Issued: ______________ _ Date and Time Expires:

Job site/Space I.D.: ______________ _ Equipment to be worked on: _______ ____ _

Job Supervisor Work to be per·�f�o � rm =-e�d�:----------------

Stand-by personnel ______________________________________________ _

1. Atmospheric Checks: Time Oxygen ____ % Explosive ____ % L.F.L.

Toxic PPM

2. Tester's signature ______ _

3. Source isolation (No Entry): N/A

Pumps or lines blinded, ( ) disconnected, or blocked ( )

4. Ventilation Modification: N/A Mechanical ( ) Natural Ventilation only ( )

5. Atmospheric check after isolation and Ventilation:

Oxygen ______ % > Explosive. ____ % L.F.L. < Toxic ______ PPM < Time ___ ,_-.,-- Testers signature _____ _

6. Communication procedures:

7. Rescue procedures:

Yes No Yes No

19.5 % 10 %

10 PPM H2S

8. Entry, standby, and back up persons: Yes No Successfully completed required training?

Is it current? ( ) ( )

9. Equipment: N/A Direct reading gas monitor -tested Safety harnesses and lifelines for entry and standby persons ( Hoisting equipment ( Powered communications ( SCBA's for entry and standby persons ( Protective Clothing ( All electric equipment listed

Class I, Division I, Group D and Non-sparking tools (

10. Periodic atmospheric tests:

Yes No oxygen __ % Time __ Oxygen __ % Time __ oxygen __ % Time __ oxygen __ % Time __ Explosive % Time Explosive % Time Explosive=% Time== Explosive==% Time== Toxic % Time Toxic % Time Toxic =% Time== Toxic ==% Time==

We have reviewed the work authorized by this permit and the information contained here-in. 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 (Cs Operations Personnel) : ____________ --------------,.-,---,---------

(pnnted name) (signarure) This permit to be kept at job site. Return job site copy to Safety Office following job completion.

Copies: White Original (Safety Office) Yellow (Unit Supervisor) Hard(Job sire)

Appendix D - 2

ENTRY PERMIT

PERMIT VALID FOR 8 HOURS ONLY. ALL PERMIT COPIES REMAIN AT SITE UNTIL JOB COMPLETED

DATE: - - SITE LOCATION/DESCRIPTION ___________________________ _

PURPOSE OF ENTRY

SUPERVISOR(S) in charge of crews Type of Crew Phone#

COMMUNICATION PROCEDURES

RESCUE PROCEDURES (PHONE-:-;

NU�M

B=ER=s=-A�T=-B=o�T�T=o�M�):--

* BOLD DENOTES MINIMUM REQUIREMENTS TO BE

REQUIREMENTS COMPLETED DATE TIME

Lock out/De-energize/Try-out __ _ _ Line(s) Broken-Capped-Blank PUrge-Flush and vent

Ventilation Secure Area (Post and Flag) Breathing Apparatus __ _ _ Resuscitator - Inhalator standby Safety Personnel == == Note: Items that do not apply enter N/ A in the blank.

COMPLETED AND REVIEWED PRIOR TO ENTRY*

REQUIREMENTS COMPLETED DATE TIME

FUll Body Harness w/11O11 ring __ _ _ Emergency Escape Retrieval Eq __ _ _ Lifelines Fire Extinguishers

Lighting (Explosive Proof) == == Protective Clothing __ _ _ Respirator(s) (Air PUrifying) Burning and Welding Permit

** RECORD CONTINUOUS MONITORING RESULTS EVERY 2 HOURS **

CONTI NUOUS 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 &/OR UNIT#

SAFETY STANDBY PERSON IS REQUIRED FOR ALL CONFINED SPACE WORK

SAFETY STANDBY PERSON(S) CHECK# CONFINED SPACE ENTRANT(S) CHECK# CONFINED SPACE ENTRANT(S) CHECK#

SUPERVISOR AUTHORIZATION - ALL CONDITIONS SATISFIED_--=---::-----,-.,---,--� DEPARTMENT/PHONE AMBULANCE 2800 FIRE 2900 Safety 4901 Gas Coordinator 4529/5387