S02_CONFINED SPACE PERMIT Fillable.pdf

PERMIT REQUIRED CONFINED SPACE PERMIT

PART I To Be Completed by Supervisor, Facilities Management Program

1. DATE OF PLANNED ENTRY__________________________________________________

2. ESTIMATED TIME SPACE IS TO BE OCCUPIED (Hrs) ________________________

3. LOCATION OF THE PERMIT SPACE__________________________________________

4. DESCRIPTION OF WORK TO BE PERFORED IN THE PERMIT SPACE

5. DESCRIPTION OF HAZARDS: _______________________________________________

6. ISOLATION CHECKLIST: (Attach copy of each completed Lockout procedure)

Electrical Isolation________________________________________________________

Mechanical Isolation______________________________________________________

Isolation of Water or Steam________________________________________________

Other Isolation___________________________________________________________

7. HOT-WORK PERMIT REQUIRED? ___________________________________

8. ENVIRONMENTAL CONDITIONS THAT MUST BE MAINTAINED DURING ENTRY

THIS ENTRY PERMIT IS VALID ONLY

FROM: Date _____________ Time ____________ TO: Date _____________ Time ___________

Name of Supervisor (Print/Type) Date

Signature

PART II To Be Completed by Contractor’s Entry Supervisor

1. LIST THE FOLLOWING NAMES OF PERSONS:

ENTRANTS ATTENDANTS

2. TYPE OF VENTILATION TO BE USED_____________________________________________

3. DESCRIPTION OF CONTROLS REQUIRED TO ENSURE HAZARDS AND ENVIRONMENTAL

CONDITIONS IDENTIFIED IN PART I ARE MAINTAINED AT ALL TIMES DURING ENTRY

4. DESCRIPTION OF PHYSICAL BARRIERS TO PREVENT UNAUTHORIZED ENTRY INTO

SPACE

5. MEANS OF COMMUNICATION BETWEEN ENTRANTS AND ATTNDANTS

6. PERSONAL PROTECTIVE EQUIPMENT TO BE USED

Protective Clothing: _________________________________________________________________

Head, Hand, or Foot Protection: ______________________________________________________

Hearing or Eye Protection: ___________________________________________________________

Respiratory Protection: ______________________________________________________________

Other Protection: ____________________________________________________________________

7. NAME OF RESCUE SERVICE PERSONNEL

8. RESCUE EQUIPMENT TO BE USED

9. FREQUENCY OF PERIODIC ATMOSPHERIC TESTING

(If continuous air monitoring equipment is not used) ________________________

10. RESULTS OF ATMOSPHERIC TESTING:

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

Date Time CO H2S O LEL (lower explosive limit)

* Required for Safety approval of Permit. (See next page for recording additional re-entry test results)

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

Name Contractor’s Entry Supervisor: ________________________________________________ (Print or Typed)

Signature of Contractor’s Entry Supervisor: __________________________________________

Date: __________________________________ Time: _________________________________

PART III To Be Completed by the Safety Manager (or designee)

SAFETY OFFICE APPROVAL OF PERMIT ENTRY

I have reviewed the above with the Contractor’s Entry Supervisor and found all controls required for this permit to be in place. I have informed the Contractor’s Entry Supervisor that all controls required by this permit are to remain in place for duration of occupancy of the space, and have provided the Contractor’s Entry Supervisor with Medical Center emergency contact information.

Name of Safety Manager (or designee) Signature of Safety Manager (or designee)

Date: __________________________________ Time: _________________________________

NOTE: This permit is to be posted at entrance of space prior to entry, and shall remain posted until occupancy of space is completed.