§5157. Permit-Required Confined Spaces,  Appendix D-1. Confined Space Entry Permit 

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
     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 Safety
Office following job completion.

Copies:   White Original (Safety Office)
          Yellow (Unit Supervisor)
          Hard(Job site)

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