Attachment 4 - AF1024 Confined Space Entry Permit.pdf

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CONFINED SPACE ENTRY PERMIT

See AFI 91-203, Chapter 23 for detailed instructions.

2. General Information Identify any TO or OI that Covers Entry Authorized Duration of Permit

3. Hazards (Indicate all probable hazards) On or Off Installation, Location (GPS coordinates if known) & Description of Space to be Entered Purpose of Entry

1. Master Entry Plan (MEP) Is Entry Covered by a CSPT Approved MEP?

4. Hazard Controls Personal Protective Equipment Respiratory Protection Communication Rescue Equipment Other (any other hazards controls required by applicable TO, OI, etc.)

5. Preparation for Entry (Any item in this section that is inconsistent with MEP is not a routine entry) Ventilation Methods Communication Methods Additional Permits Other (any other required by applicable TO, OI, etc.)

Personnel Awareness

AF FORM 1024, 20160322

Previous editions currently in use as of date of this form are authorized - All others are obsolete.

Adobe® LiveCycle® Designer ES4 OPR: HQ AFSEC/SEGS Monitoring Device Entry Supervisor(s) Entry Supervisors should verify that the appropriate information has been recorded on the confined space entry permit, that other specified permits and all tests specified by the permits have been completed, and that all requirements, procedures, and equipment specified by the permit have been satisfied or are in place before issuing the permit to authorize entry.

Atmospheric Monitor(s) Atmospheric Monitors should be qualified in the appropriate selection, inspection, calibration, testing, adjustment and use of monitoring equipment and applicable monitoring and testing procedures needed to assess and evaluate atmospheres in and around confined spaces.

Grade Name (Last, First MI) Grade Name (Last, First MI)

7. Authorized Personnel (All listed authorized supervisors must be consistent with MEP to be a routine entry)

10. Entry Time Log Entrant(s) Attendant(s) Attendants should understand and be able to communicate to the Entry Supervisor the hazards inside and outside the specific confined space that might occur during entry, including information on the modes, signs or symptoms, and consequences of exposure to Entrants.

Grade Name (Last, First MI) Signature Grade Name (Last, First MI) Signature Name (Last, First MI) Time In Time Out Time In Time Out Time In Time Out Time In Time Out Time In Time Out Time In Time Out

9. Coordination (Not required for entries consistent with an approved MEP) Occupational Safety (SEG) Bioenvironmental (BE) Fire Emergency Services (FES)

11. Close-out / Cancellation This permit must be available on job site during entry.

Maintain the job site copy on file in work center for one year.

6. Atmospheric Testing & Monitoring Record (Continuous monitoring shall be performed during all construction confined space operations) Continuous monitoring shall be performed during all construction confined space operations. All other operations shall follow the requirements in AFI 91-203, paragraph 23.3.9.

Type Hazard Acceptable Entry Conditions Occupational & Environmental Exposure Limits (OEEL) Time / Result Time / Result Time / Result Time / Result Time / Result Time / Result Time / Result Time / Result Time / Result Time / Result Time / Result Time / Result Oxygen (O2) 19.5% - 23.5% Carbon Monoxide (CO)

+35 PPM

Flammables (LEL) Under 10% Toxic Gases and Vapors - e.g., Sulfur Dioxide (SO2), Chlorine (Cl), Hydrogen Sulfide (H2S), Volatile Organic Compound (VOC), etc.

Tester Initials

8. Fire Emergency Services or Equivalent Point of Contact (Last, First MI) Contact Info (Phone #, Radio Call Sign, etc.)

Date/Time Rescue Service Confirmed Continuous monitoring required?

Additional testing/monitoring or entrant information attached?

AF FORM 1024, 20160322

11.0.1.20130826.2.901444.899636 412-474-8015 412-474-8234 304-238-4620 Rescue Team 412-474-8250 Safety 724-683-4324 Bio 724-312-1119