ATTACHMENT F Confined space permit.xlsx

IMP Permit

1 Service Work Order #: 2008-xxxxxx Service Work Order #: 2008-xxxxxx

Project Title: Project Title: 0

Permit Issued To: Phone: 9 ATMOSPHERIC HAZARDS: PHYSICAL HAZARDS:

4 AREA COVERED: Misc:

The above requestor has approval for confined space entry with the understanding that all safety codes and regulations will be followed. 14 WORK SUPERVISOR GAS FREE TECH

GENERAL INSTRUCTION

Summary:

The Confined Space Permit Form is to be used for all maintenance, repairs, modifications and upgrades when confined space requirements exist. All work must be authorized and approved through the appropriate zone management and/or designated persons. Using this form should help prevent miss communication and assure continuity of work among various shops and departments within the Office of Facility Engineering and Operation (OFEO).

Purpose:

This permit is to be used for all maintenance, repairs, modification and/or upgrades in order to minimize communication failures and work disruptions. It also helps to ensure all appropriate shops and departments are contacted while confined work is being performed. This forms helps ensure that codes and regulation are followed while maintaining historical records of work.

Instructions:

1. Tracking Control # / Control Number SWO# – Select the appropriate control number and enter the tracking number. The OFMR group will use an SWO for the tracking number. The tracking number will be used for a reference to work which allows us to pull historical records for labor and material cost. All individuals in the Office of Facility Maintenance & Reliability (OFMR) working on this permit should use the same number.

SI In-House and Contractor – check either or both if work involves in-house and outside contract work.

2. Name of Building – select from the drop down list the location of work. If unable to find a proper location use the blank and type in the building name.

Project Title – show project title if applicable.

Permit Issued To and Requested By - Permit Issued to specify the individual who will be responsible for coordinating all shops in order to accomplish work.. The requested by identified who is asking to have the work done. Provide a phone numbers (xxx xxx-xxxx.).

Requester and Phone – use this block for the requester’s name that work is being requested. Example: Work request may come from Building Management, Safety Office and / or the Office of Engineering, Design and Construction.

3. Exact Location of the Valve/Zone – enter the valve location and identification number. Copy of this permit will be posted at the valve location at a visible site.

4. Area Covered - provide some detail of the zones and/or areas affected by this work.

5. Reason for Entry - select from the drop downs and provide an emergency phone number ( xxx xxx-xxxx ). the Confined Space Entry Supervisor and / or Project Manager / Contracting Offers Technical Representative (COTR) shall print first, last name and sign requesting confined space entry work. Provide the permit start date and time, permit expire date and time by using the drop downs.

6. Notification - Precautions Taken (check as appropriate) – use the list and check those that are appropriate. The Work Supervisor / Leader will provide notification to the Building Security Control Operator, Building Management, and Work Management Center (WMC) by providing a copy of the permit prior to any work other than extreme emergencies. Other precautions are noted whether or not hot work is allowed or prohibited, lockout & tagout and / or other permits required.

7. Additional Comments – use this block to provide more specific information.

8. Authorized By – The Confined Space Permit must be authorized by the Zone Manager or designated person. Provide the first, last name and title (print) and initial.

9. Atmospheric Hazards – identify by checking box. Enter names of authorized entrants and attendants. Use drop downs to select (yes, no, or n/a) for source isolation and ventilation modifications.

10. Personal Protective Equipment – selected by using drop downs or entering equipment. Answer communication questions and show type of Gas Monitor Used. The gas monitor must be in calibration – answer by selecting drop down.

11. Test and Acceptable Entry Conditions – monitor the confine space hourly for conditions, indicate n/a if not appropriate, show time and initial. Traffic Controls – answer by checking what measures have been taken.

12. Special Training – make note of any special training.

13. Special Requirements and Permits – Check ( yes, no, or n/a ) whether or not other permits are required.

14. Work Supervisor and Gas Free Tech – provide following up on confined space work and initial.

15. Confined Space Entry Supervisor – use this block to make additional comments if needed.

16. Confined Space Entry Supervisor, Project Manager and / or COTR - authorized by first, last name ( print ) and initial.

Created by John Standish (12/2008)