Confined Space Entry Permit

Confined Space Entry Permit

ReconAfrica
Effective Date:

MonthDayYear
Date
Effective Time:

Hour Minutes
Expiration Date:

MonthDayYear
Date
Expiration Time:

Hour Minutes
Permit Issued To:
Email:
example@example.com
Lease or Area:
Specific Location (e.g. tank or vessel)
Description of Work:
Potential Hazards of Space:
Documents:

JSA AttachedEnergy Control Procedure/Blinds UsedC.S. Evaluation & Information SheetSDSEntrant Log
Preparation:

Powered (forced air) VentilationEquipment Piping Blinded, Blanked or MisalignedVessel/Space Cleaned, Cleared and ventedOther

Atmospheric Oxygen Testing:

	Test 1	Test 2	Test 3	Test 4	Test 5
Time
%
Tracked By:

Atmospheric Oxygen Testing:

	Test 6	Test 7	Test 8	Test 9	Test 10
Time
%
Tracked By:

Oxygen Action Level:

Less Than 18.696% NO ENTRY

Greater Than 28.696% NO ENTRY

Flammable:

	Test 1	Test 2	Test 3	Test 4	Test 5
Time
LEL
Tracked By:

Flammable:

	Test 6	Test 7	Test 8	Test 9	Test 10
Time
LEL
Tracked By:

LEL Action Level:

Grerater Than 10% NO ENTRY

Hydrogen Sulfide:

	Test 1	Test 2	Test 3	Test 4	Test 5
Time
PPM
Tracked By:

Hydrogen Sulfide:

	Test 6	Test 7	Test 8	Test 9	Test 10
Time
PPM
Tracked By:

PPM

Grerater Than 10 PPM NO ENTRY
Protective Equipment:

Warning Signs/BarriersBarricade Tape/ConesVentilation or BlowerSCBAAir Supplied RespiratorChemical Splash Goggles/Face ShieldSafety GlassesFire ExtinguisherGround Fault Circuit InterrupterLighting (explosion proof low voltage)Impervious GlovesImpervious ClothingRubber BootsHearing ProtectionStatic ProtectionLadderFall Protection/Retrieval EquipmentFull Body Harness/LifelineOther
Emergency Phone number:
Location of Phone/Radio:
Rescue Team:

On-CallOn-SiteTier ITier II
Rescue Readiness:

Rescue WinchWristletsSCBA StandbyPersonal Motion AlarmDault/Tripod
CSI Communication W/Entrants

Radio CommunicationVocal CommunicationsVisual/Hand SignalsRope SignalsOther
Potential Emergency Situation:
Action to be Taken
CONFINED SPACE ENTRANT(S): I (we) have reviewed the requirements of this permit, the potential emergency situations and actions to be taken. I (we) are familiar with the contingency plans, all rescue equipment, and communication methods.
Confined Space Entrant(s) Signature:

Clear
CONFINED SPACE ATTENDANT, STANDBY/FIREWATCH: I (we) have checked all rescue and communication equipment and reviewed all emergency actions to be taken with entrant personnel. Rescue team has been notified.
Confined Space Attendant(s) Signature:

Clear
PERSON IN CHARGE (PIC): I have evaluated and completed all portions of this permit. All personell have reviewed the conditions of this permit and are adequatly trained to perform this job. I have reviewed the site to ensure compliance with the requirements of this permit.
Person in Charge (PIC) Signature:

Clear
RECON AFRICA REPRESENTATIVE: I have reviewed this permit for completeness and have informed the person in charge (PIC) of recognised process hazards. I have reviewed the prep items with the PIC and agree the identified prep items shall be performed. I have reviewed the site to ensure compliance with the requirements of this permit.
Recon Africa Representative Signature:

Clear
Were any hazards or potential hazards uncovered during the CSE?

NOYES (check boxes below)Unanticipated HazardIncomplete JSAEnergy Control Procedures Incorrect (update required)Other
Comments:
Should be Empty: