Confined Space Entry Permit

Confined Space Entry Permit

Space:
Purpose:
Entry Supervisor:
Attendant:
Entrant(s):

1: Master’s Pre-Entry Authorization

I have reviewed the request and authorize the space opened for pre-entry evaluative testing.  No entry is permitted until permit is complete and all required signatures obtained.

Master                                   Date

2: Atmospheric Evaluation Testing by Licensed Officer (before isolation/ventilation)

Date:			Time:
Inst. Type			Tester’s initials:
O2%:			LEL%:
Toxic			ppm:

3: Source Isolation

	N/A	Yes	No
Pumps / Lines	¨	¨	¨
Blind Flanged	¨	¨	¨
Disconnected / Blocked	¨	¨	¨

4: Ventilation

	N/A	Yes	No
Mechanical	¨	¨	¨
Natural Ventilation Only	¨	¨	¨

5: Atmospheric Evaluation Testing by Licensed Officer (after isolation/ventilation)

Date:			Time:
Inst. Type			Tester’s initials:
O2%:			LEL%:
Toxic			ppm:

6: Required

Full Body Harness with D ring	¨
Emergency Escape Retrieval Equipment	¨
Lifelines	¨
SCBAs	¨
Standby Personnel Alerted	¨
Secure Area (posted & barriers)	¨

Date and Time of Issue	/    /       __:__
Date and Time Expires	/    /       __:__

7: Other

		N/A	Yes	No
Fire extinguishers		¨	¨	¨
Lights (explosion proof)		¨	¨	¨
Protective Clothing		¨	¨	¨
Respirators		¨	¨	¨
Communications Between:
Attendant and Entrant			¨
How?
Attendant and Rescue			¨
How?

8: Special Conditions

9: Entry Supervisor’s Signature

I understand my responsibilities and agree to abide by the conditions of this permit.  If any of the conditions change or are unable to be met, work must stop until a new permit has been issued.

Entry Supervisor                                   Date

10 Chief Engineer’s Signature

I have reviewed the work authorized by this permit and the information contained herein.  Instructions and safety procedures have been given, received and understood

Chief Engineer                                   Date

Master’s Signature

I have reviewed the work authorized by this permit and the information contained herein.  All items on this permit have been completed and I authorize space to be entered.

Master                                   Date

PERMIT MUST BE POSTED AT JOB SITE

Permit valid for a maximum of 10 hours and must be reissued for a break in work of 6 or more hours.

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