Written Programs : Permit-Required Confined Space Program: Entry Permit

ENTRY PERMIT
GENERAL INFORMATION	CONTROLS/EQUIPMENT Check all that apply
Permit Space Location: __________________________Purpose of Entry: _________________ Entry Permit Valid For: Date: __________ to Date: ________ Time: __________ to Time: ________ PERMIT SPACE HAZARDS ATMOSPHERIC Yes/No Oxygen Deficiency Y/N Oxygen Enrichment Y/N Explosive (Gas/Vapor) Y/N Explosive Dust Y/N Carbon Monoxide Y/N Hydrogen Sulfide Y/N Other Toxic gases/vapors Y/N ENGULFMENT Y/N CONFIGURATION (ENTRAPMENT) Y/N MECHANICAL Y/N ELECTRICAL Y/N SUBSTANCE HAZARDOUS TO SKIN OR EYES Y/N HEAT STRESS Y/N OTHER POTENTIAL HAZARDS (e.g., radiation, noise, etc.) Y/N _________________________ _________________________ PERSONNELEntrant(s) -Time In- Time Out ______________________ ______________________ ______________________ Attendant(s) __________________________ ____________________________________ Entry Supervisor(s) _____________________ ____________________________________ COMMUNICATION PROCEDURES USED BY ENTRANT(S) and ATTENDANT(S) Check all that apply Visual Rope Voice Radio Other (specify) _______________________ RESCUE AND EMERGENCY SERVICES Names _______________________ Phone ___________________ Summoning Procedure ________________ __________________________________	ISOLATION LOCKOUT/TAGOUT BLANKING/BLINDING DOUBLE BLOCK AND BLEED LINE BREAKING/MISALIGNMENT OTHER _______________________ INERTING PURGE/CLEAN METHOD FOR SAFE COVER REMOVAL & SECURING AREA ATMOSPHERIC TESTING Periodic (give interval) _____________ Continuous VENTILATION Natural Continuous forced air Local Exhaust ENTRY EQUIPMENT Ladders Other ________________________ PERSONAL PROTECTIVE EQUIPMENT Respiratory - SCBA, SAR, Air Purifying Clothing (specify)______________ Eye and face protection Hearing protection RESCUE AND RETRIEVAL EQUIPMENT Full body harness Lifeline Tripod w/mechanical winch Explosion proof lighting NON-SPARKING TOOLS INTRINSICALLY SAFE ELECTRICAL EQUIP MENT & GFCI COMMUNICATION EQUIPMENT Radio Phone Other ____________________ HOT WORK PERMIT FIRE EXTINGUISHERS RESCUE PROCEDURES __________________________ __________________________ __________________________ __________________________ __________________________