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CONFINED SPACE ENTRY PERMIT
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Demo Project
Jobsite Area :
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LOCATION*
UBICACIÓN*
START (Hour)*
INICIO (Hora)*
FINISH (Hour)*
FINALIZAR (Hora)*
JOB DESCRIPTION*
DESCRIPCIÓN DEL TRABAJO*
TYPE OF SPACES
High-temperatuer manhole
Electrical/phone manhole
Sanitary manhole
Lift Station
Water meter pit
Other(Specify) :
ATMOSPHERIC SAMPLING CONDUCTED BY (Complete 4-6)
NAME (Signatuer)
Using your finger, sign on the line below:
clear signature
TITLE
DATE
ATMOSPHERIC SAMPLING REQUIRED)
Prior to Ventilation/start of job(always required)
Periodically during occupancy
Continuously during occupancy
ATMOSPHERIC SAMPLING INSTRUMENT MANUFACTURE AND MODEL#
SERIAL NUMBER
DATE OF LATEST CALIBRATION
ATMOSPHERIC SAMPLING REQUIRED
Sample
ACCEPTABLE RANGES
RESULT
AM
PM
RESULT
AM
PM
RESULT
AM
PM
RESULT
AM
PM
RESULT
AM
PM
MINIMUM
MAXIMUM
Oxygen
19.50%
23%
Flammable gas/vapors
0%
10% LEL
Others (Specify)
0%
10% PPM
Temperature
NOTE: 1. If levels are outside the acceptable levels specified above. entry is denied until 3 consecutive lest are done 5 minutes apart with or without mechanical ventillation. indicate. 2. If additional space is needed. record sampling results on back.
VENTILATION
No mechanical ventilation required
Continuous mechanical ventilation required
* For high-temperature spaces and/or if any atmospheric data are outside acceptable ranges or if chemical hazards are present, ventilate at least 15 minutes prior to entry.
EMERGENCY PERSONNEL STANDBY
Not required
Fire/Rescue Protective Service
Notes/Comments:
Safety Officer
Other
(Specify):
PROTECTIVE EQUIPMENT REQUIRED
Type "C" supplied-air respirator
Full body coverings
Other respiratory protection
(Specify):
Two-way radio
Hearing Protecction
Fire extinguisher
Coveralls
Safety harness/life is required if:1 Any sampling data is outside acceptable ranges. 2. Type "C" supplied-air respirator is required. 3. Moderate/high risk of bumbs or scalds. or 4. During emergency rescue . Harness/life use requires the fire protection services to be notified.
ISOLATION OF MECHANICAL, ELECTRICAL, PHYSICAL OR CHEMICAL ENERGY SOURCES REQUIRED ?
NO
YES
(Specify):
HAS SPACE CONTAINED LIQUIDS GASES OR SOLIDS OF TOXIC, CORROSIVE OR IRRITANT NATURE?
NO
YES
If Yes, contact to the Supervisor and the Risk Management Branch prior to entry.
NAME OF ATTENDANT (Must maintain visualy/voice contact with personal in space.)
NAME(S) OF EMPLOYEE(S) AUTHORIZED TO ENTER
SPECIAL INSTRUCTIONS/EQUIPMENT
The job described above has been reviewed and it is agreed that it will be accordance with requirements specified herein.
QUALIFIED PERSON (Print and Sign) :
Using your finger, sign on the line below:
clear signature
DATE:
EMERGENCIES
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