Appendix D to §1910.146 -- Sample Permits
Appendix D-1
Confined Space Entry Permit
Date and Time Issued: ______Date and Time Expires: ______
Job site/Space I.D.: ______Job Supervisor:______
Equipment to be worked on: ______Work to be performed: ______
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 Yes No
Pumps or lines blinded, ( ) ( ) ( )
disconnected, or blocked ( ) ( ) ( )
4. Ventilation Modification: N/A Yes No
Mechanical ( ) ( ) ( )
Natural Ventilation only ( ) ( ) ( )
5. Atmospheric check after
isolation and Ventilation:
Oxygen ______% > 19.5 %
Explosive ______% L.F.L < 10 %
Toxic ______PPM < 10 PPM H(2)S
Time ______
Testers signature: ______
6. Communication procedures: ______
______
7. Rescue procedures: ______
______
______
______
8. Entry, standby, and back up persons: Yes No
Successfully completed required
training?
Is it current? ( ) ( )
9. Equipment: N/A Yes No
Direct reading gas monitor -
tested ( ) ( ) ( )
Safety harnesses and lifelines
for entry and standby persons ( ) ( ) ( )
Hoisting equipment ( ) ( ) ( )
Powered communications ( ) ( ) ( )
SCBA's for entry and standby N/A Yes No
persons ( ) ( ) ( )
Protective Clothing ( ) ( ) ( )
All electric equipment listed
Class I, Division I, Group D
and Non-sparking tools ( ) ( ) ( )
10. Periodic atmospheric tests:
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) :
______
(printed name) (signature)
This permit to be kept at job site. Return job site copy to SUPERVISOR
following job completion.
Appendix D - 2 ENTRY PERMIT
PERMIT VALID FOR 8 HOURS ONLY. ALL COPIES OF PERMIT WILL REMAIN AT JOB SITE UNTIL JOB IS COMPLETED
DATE:______SITE LOCATION and DESCRIPTION ______
PURPOSE OF ENTRY ______
SUPERVISOR(S) in charge of crews Type of Crew Phone #
______
______
COMMUNICATION PROCEDURES List type of Alarms______
RESCUE PROCEDURES/EQUIPMENT (PHONE NUMBERS AT BOTTOM) ______
______
DENOTES MINIMUM REQUIREMENTS TO BE COMPLETED AND REVIEWED
PRIOR TO ENTRY*
REQUIREMENTS COMPLETED DATE TIME
Lock Out/De-energize/Try-out ______
Line(s) Broken-Capped-Blanked ______
Purge-Flush and Vent ______
Ventilation ______
Secure Area (Post and Flag) ______
Breathing Apparatus ______
Resuscitator - Inhalator ______
Standby Safety Personnel ______
Full Body Harness w/"D" ring ______
Emergency Escape Retrieval Equip ______
Lifelines ______
Fire Extinguishers ______
Lighting (Explosive Proof) ______
Protective Clothing ______
Respirator(s) (Air Purifying) ______
Burning and Welding Permit ______
Note: Items that do not apply enter N/A in the blank.
**RECORD CONTINUOUS MONITORING RESULTS EVERY 2 HOURS
CONTINUOUS 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 INSTRUMENT(S) MODEL SERIAL &/OR
& CHECK # USED &/OR TYPE UNIT #
______
______
SAFETY STANDBY PERSON IS REQUIRED FOR ALL CONFINED SPACE WORK
SAFETY STANDBY CHECK # CONFINED CONFINED
PERSON(S) SPACE CHECK # SPACE CHECK #
ENTRANT(S) ENTRANT(S)
______
______
SUPERVISOR AUTHORIZING - ALL CONDITIONS SATISFIED______
PHONE ______
AMBULANCE______FIRE ______Safety______Gas Coordinator______
List any other permit required in confined space (Hot Work, etc)______
______
File copy at office.
CONFINED SPACE ENTRY LOG
This log must:
Be filled out and kept current as each person enters or leave the confined space,
Must be maintained at the entrance to the confined space, and
Is part of the confined space entry permit and must be filed with the permit.
DATE:______
ATTENDANT: ______
HOT WORK / ENTRY PERMIT NUMBER______
EQUIPMENT IDENTIFICATION _(TANK, VESSEL ETC)______
PRINT NAME SIGNATURE TIME IN TIME OUT
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
COMMUNICATION PROCEDURE:
In general, the Attendant will be in communication with the Entrants at all time. The attendant can use the necessary communications tools to maintain communications such as radio, air horn, or other signal devices. Should emergency or rescue services be required, the Attendant is to immediately summons appropriate services.
If special procedural information is required is should be indicated below:
______
______
______
______
______
______
(useadditional pages as required)