Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Time
Hour Minutes
AM
PM
AM/PM Option
Description of Work to be Performed:
Jobsite
Location of Confined Space:
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Entry Checklist
Yes
No
Potential Hazards Identified?
Communications Established with Safety Manager?
Emergency Procedures Reviewed?
Entrants and Attendants Trained?
Isolation of Energy Completed?
Area Secured?
Emergency Escape Retrieval Equipment Needed?
Emergency Escape Retrieval Equipment Needed?
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Confined Space Equipment and PPE Used During Entry
Tripod with Mechanical Winch
Rescue Tripod with Lifeline
Chemical Resistant Clothing
General/Local Exhaust Ventilation
Other PPE or Equipment Used
Air Purifying Respirator
Self Contained Breathing Apparatus
Two-Way Communications
Safety Glasses/Goggles/Face Shield
Gloves
Hard Hat
Harness
Hearing Protection
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Air Monitoring Results Prior to Entry
Monitor Type
Serial Number
Oxygen %
LEL%
CO%
H2S%
Calibration Performed?
Yes
No
Alarm Conditions?
Yes
No
Initials
Monitoring Performed By
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
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Continuous Air Monitoring Results
Time
Hour Minutes
AM
PM
AM/PM Option
Oxygen %
LEL %
CO %
H2S %
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Authorization
We have reviewed the work authorized by this permit and the information contained herein. Written instructions and safety procedures have been received and are understood. This permit is not valid unless all appropriate items are completed. This permit is to be kept at the jobsite. Return copy to supervisor.
Entrant(s) Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Attendant's Name(s)
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Supervisor's Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
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