Non-Permit Required Confined Space Entry Permit

Non-Permit Required Confined Space Entry Permit
***Notice***

Although this permit is not required for non-permit-required confined space entry activities on a Pulsar Helium (the Company) location, it is made available as an example to contractors who provide services to Pulsar Helium. The Company requires contractors to utilize their company-provided permitting system when conducting non-permit-required confined space entry work on a Company location.
Date

MonthDayYear
Date
Job Supervisor

First NameLast Name
Supervisor Email
example@example.com
Operating Group
Permit Location
Reason for Entry
Expected Duration of Entry
Atmospheric Test Results
% of Oxygen (allowable level 19.5% to 23.5%):
% LEL (allowable level 0%):
Carbon Monoxide (allowable level 0%)
Carbon Dioxide (allowable level 0%)
Determination
1. Is the gas monitor current with calibrations
2. Are test readings within the "Allowable Level"
3. Is there a material that can engulf the entrant
4. Could entrant be trapped, crushed or smothered
5. Are there any additional uncontrolled safety hazards present
6. Can the space be maintained as safe during work
7. Are the entrants properly trained
8. Are the attendants properly trained
9. Are rescue procedures and equipment available
10. Are attendants rotated every two hours
The above answers should be 'NO' to question 3, 4, and 5, and 'YES' to question 1, 2, 6, 7, 8, 9 and 10. If any of your answers are different, you must fill out a 'Permit Required Confined Space Entrance Permit' located at www.ssandt.solutions. Do you understand?
Acceptance
Entrant(s)
Entrant(s) Signature(s)
Attendant(s)
Attendant(s) Signature(s)
Supervisor Signature
Should be Empty:

Non-Permit Required Confined Space Entry Permit

Atmospheric Test Results

Determination

Acceptance