Form
Permit-Required Confined Space Reclassification Form
This form must be completed and approved prior to any Validus Energy employee entering a previously classified permit-required confined space for inspection.
Person Completing Reclassification Form
First Name
Last Name
Person Conducting Inspection
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Lease or Location
Equipment being inspected
Job Scope
Hazard Mitigation
Any NO answer cancels all Validus Energy employee entry.
Hazard 1
Hazard Identified
Mitigation Method
Has the Hazard been removed Prior to Entry?
Yes
No
Hazard 2
Hazard Identified
Mitigation Method
Has the Hazard been removed Prior to Entry?
Yes
No
Hazard 3
Hazard Identified
Mitigation Method
Has the Hazard been removed Prior to Entry?
Yes
No
Hazard 4
Hazard Identified
Mitigation Method
Has the Hazard been removed Prior to Entry?
Yes
No
Hazard 5
Hazard Identified
Mitigation Method
Has the Hazard been removed Prior to Entry?
Yes
No
Hazard 6
Hazard Identified
Mitigation Method
Has the Hazard been removed Prior to Entry?
Yes
No
Hazard 7
Hazard Identified
Mitigation Method
Has the Hazard been removed Prior to Entry?
Yes
No
Air Monitoring Results
Air must be continuously monitored while any personnel are in the space.
Person Conducting Air Monitoring
First Name
Last Name
Time air monitoring was conducted (no more than 5 minutes prior to entry)
Hour Minutes
AM
PM
AM/PM Option
Oxygen
Must be greater than 19.5% and less than 21.5%
LEL
Less than 10%
Hydrogen Sulfide (H2S)
Less than 10 PPM
Carbon Monoxide (CO)
Less than 10 PPM
Approvals
Operations Approval (Foreman or Above)
First Name
Last Name
Method of Approval
EHS Approval
First Name
Last Name
Method of Approval
Submit
Should be Empty: