Confined Space Permit Confined Space Pre-Entry Assessment ...
Transcript of Confined Space Permit Confined Space Pre-Entry Assessment ...
Confined Space Permit
Confined Space Pre-Entry Assessment
Equipment to be worked on:
Purpose of Entry:
Person originating assessment: Date: Time:
Pre-Entry Atmosphere Check by (Name): Date: Time:
Oxygen > 19.5% and < 23.5% %
LEL: < 10% LEL (Pentane) % Test Meter Information
CO: < 35 ppm ppm Make:
Model:
Serial:
H2S: < 10 ppm ppm
SO2: < 2 ppm ppm
Toxics:
Confined Space Hazards At Time of Entry
1. Does this space contain or have the potential to contain a hazardous atmosphere?
Yes No
- Flammable gases or vapors? Yes No
- Dusts that can reach concentrations to be explosive? Yes No
- Oxygen levels below 19.5% or above 23.5%? Yes No
- Any other condition that is immediately dangerous to life and health. Yes No
2. Does this space contain a material that has the potential for engulfing an Entrant?
Yes No
3. Does this space have an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or floor?
Yes No
4. Does this space contain any other recognized serious safety and health hazards? Yes No
5. Will ventilation be required to remove or eliminate the hazards during the entry?
Yes No
If any boxes are checked “Yes”, then this is a Hazardous Confined Space and rescue planning is required
Describe the methods used to remove the hazards, including Lock Out/Tag Out, Sampling, etc.
Lock Out/Tag Out:
Other Methods Used:
1. Is continuous monitoring to be used? Yes No
2. Is continuous ventilation to be used Yes No
If “No”, why
Circle One: Non-Hazardous Space Hazardous Space – (Additional requirements)
Supervisor Approval For Entry: Date:
Note: Completed form should be displayed at entry point and forwarded to EH&S after work is complete.
Testing and Monitoring Checklist
Make, Model and Serial Number of Testing Equipment:
Date Calibrated
Acceptable Conditions Test 1 Test 2 Test 3 Test 4 Test 5 Test 6
Date:
Time:
Oxygen > 19.5% and < 23.5% % % % % % %
LEL: < 10% LEL (Pentane) % % % % % %
CO: < 35 ppm ppm ppm ppm ppm ppm ppm
H2S: < 10 ppm ppm ppm ppm ppm ppm ppm
SO2: < 2 ppm ppm ppm ppm ppm ppm ppm
Toxics
Tested By:
Authorized Entrants/Attendants – Identify Entrant or Attendant
Name Entrant
or Attendant Time Time Time
In Out In Out In Out
Date: Completion of Permit: Supervisor Signature: Time:
Cancellation of Permit
Reason for Cancellation:
Supervisor Signature: Date: Time: