Permit Required Confined Space Entry Permit
Date
-
Month
-
Day
Year
Date
Jobsite/Location
Luarel
Other
Purpose of Entry
Supervisor in Charge of Crew:
First Name
Last Name
Supervisor authorizing Entry:
First Name
Last Name
Permit Duration
Communication Procedure (including equipment)
Rescue Procedures (also see emergency contact phone numbers at end of form)
Requirements Completed
Time and Date
Lockout/De-Energize/Try-out
Line(s) Broken-Capped-Blank
Purge-Flush and Vent
Ventilation
Secure Area
Lighting (Explosion Proof)
Hotwork Permit
Fire Extinguishers:
Supplied Air Respirator (N/A if alternate entry)
Respirator(s) (Air Purifying)
Protective Clothing
Full Body Harness w/ "D" ring
Emergency Escape Retrieval Equipment
Life Lines
Standby Safety Personnel (N/A if alternate entry)
Line(s) to be bled/blanked:
Ventilation Equipment:
PPE Clothing Required:
Respirator(s) being used:
Fire Extinguisher(s) Location:
Emergency Retrieval Equipment being used:
Atmospheric Test Results
% of Oxygen (O2) (acceptable levels 19.5% to 23.5%)
% of LEL/LFL (acceptable levels 0%)
Carbon Monoxide Level (acceptable levels 0%)
Hydrogen Sulfide (H2S) (acceptable levels 0%)
Remarks:
Air Tester Name:
First Name
Last Name
Instrument Used
Model # or Type & Serial or Unit #
Attendants and Entrants
Required for all confined space work except alternate entry
Attendant (Primary)
First Name
Last Name
Attendant (Alternate)
First Name
Last Name
Entrant
First Name
Last Name
Entrant
First Name
Last Name
Entrant
First Name
Last Name
Entrant
First Name
Last Name
Entrant
First Name
Last Name
Entrant
First Name
Last Name
Remarks:
Authorizations
Only Sign if ALL conditions have been satisfied
Supervisor Authorization:
First Name
Last Name
Supervisor Phone Number
-
Area Code
Phone Number
Emergency Contact Phone Numbers:
Ambulance:
-
Area Code
Phone Number
Fire:
-
Area Code
Phone Number
Safety:
-
Area Code
Phone Number
Rescue Team:
-
Area Code
Phone Number
Other:
-
Area Code
Phone Number
Submit
Should be Empty: