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

Admin ServicesDirt ConstructionDrillingCompletionsMechanical ConstructionWaterProductionMaintenanceWellservice/Workover
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

YesNo
2. Are test readings within the "Allowable Level"

YesNo
3. Is there a material that can engulf the entrant

YesNo
4. Could entrant be trapped, crushed or smothered

YesNo
5. Are there any additional uncontrolled safety hazards present

YesNo
6. Can the space be maintained as safe during work

YesNo
7. Are the entrants properly trained

YesNo
8. Are the attendants properly trained

YesNo
9. Are rescue procedures and equipment available

YesNo
10. Are attendants rotated every two hours

YesNo
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?

YesNo
Acceptance
Entrant(s)
Entrant(s) Signature(s)

Clear
Attendant(s)
Attendant(s) Signature(s)

Clear
Supervisor Signature

Clear
Should be Empty:

Non-Permit Required Confined Space Entry Permit

Atmospheric Test Results

Determination

Acceptance