Appendix D Confined Space Pre-Entry Check List

Confined Space Entry Permit
Date and Time Issued: _________________ Date and Time Expires: _________
Job site/Space I.D.: _____________________ Job Supervisor:___________________
Equipment to be worked on: __________ Work to be performed: _________

Stand-by personnel: __________________ ________________ _____________

1. Atmospheric Checks:

Time Oxygen Explosive Toxic

________ ________% ________% L.F.L. ________PPM

2. Tester's signature: _____________________________

3.	Source isolation (No Entry):	N/A	Yes	No
	Pumps or lines blinded,	( )	( )	( )
	disconnected, or blocked	( )	( )	( )

4.	Ventilation Modification:	N/A	Yes	No
	Mechanical	( )	( )	( )
	Natural Ventilation only	( )	( )	( )

5.	Atmospheric check after
	isolation and Ventilation:
	Oxygen ___________%	>	19.5	%
	Explosive __________% L.F.L	<	10	%
	Toxic _____________PPM	<	10	PPM H(2)S
	Time ____________
	Testers signature: _____________________________

6. Communication procedures: ________________________________________ _____________________________________________________________________

7. Rescue procedures: _______________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

8.	Entry, standby, and back up persons:	Yes	No
	Successfully completed required
	training?
	Is it current?	()	()

9.	Equipment:	N/A	Yes	No
	Direct reading gas monitor -
	tested	( )	( )	( )
	Safety harnesses and lifelines
	for entry and standby persons	( )	( )	( )
	Hoisting equipment	( )	( )	( )
	Powered communications	( )	( )	( )
	SCBA's for entry and standby
	persons	( )	( )	( )
	Protective Clothing	( )	( )	( )
	All electric equipment listed
	Class I, Division I, Group D
	and Non-sparking tools	( )	( )	( )

10.	Periodic atmospheric tests:
	Oxygen	____%	Time ____	Oxygen	____%	Time ____
	Oxygen	____%	Time ____	Oxygen	____%	Time ____
	Explosive	____%	Time ____	Explosive	____%	Time ____
	Explosive	____%	Time ____	Explosive	____%	Time ____
	Toxic	____%	Time ____	Toxic	____%	Time ____
	Toxic	____%	Time ____	Toxic	____%	Time ____

We have reviewed the work authorized by this permit and the information contained here-in. Written instructions and safety procedures have been received and are understood. Entry cannot be approved if any squares are marked in the "No" column. This permit is not valid unless all appropriate items are completed.

Permit Prepared By: (Supervisor)________________________________________
Approved By: (Unit Supervisor)__________________________________________

Reviewed By (Cs Operations Personnel) :
_________________________________	_________________________________
(printed name)	(signature)

This permit to be kept at job site. Return job site copy to Safety Office following job completion.

Copies:	White Original (Safety Office)
	Yellow (Unit Supervisor)
	Hard(Job site)

Appendix D - 2



PERMIT VALID FOR 8 HOURS ONLY. ALL COPIES OF PERMIT WILL REMAIN
AT JOB SITE UNTIL JOB IS COMPLETED

DATE: - - SITE LOCATION and DESCRIPTION ______________________________
PURPOSE OF ENTRY ______________________________________________________
SUPERVISOR(S) in charge of crews Type of Crew Phone # _______________________________________________________________________ _______________________________________________________________________
COMMUNICATION PROCEDURES ______________________________________________
RESCUE PROCEDURES (PHONE NUMBERS AT BOTTOM) ___________________________ _______________________________________________________________________
* BOLD DENOTES MINIMUM REQUIREMENTS TO BE COMPLETED AND REVIEWED PRIOR TO ENTRY*

REQUIREMENTS COMPLETED	DATE	TIME
Lock Out/De-energize/Try-out	____	____
Line(s) Broken-Capped-Blanked	____	____
Purge-Flush and Vent	____	____
Ventilation	____	____
Secure Area (Post and Flag)	____	____
Breathing Apparatus	____	____
Resuscitator - Inhalator	____	____
Standby Safety Personnel	____	____
Full Body Harness w/"D" ring	____	____
Emergency Escape Retrieval Equip	____	____
Lifelines	____	____
Fire Extinguishers	____	____
Lighting (Explosive Proof)	____	____
Protective Clothing	____	____
Respirator(s) (Air Purifying)	____	____
Burning and Welding Permit	____	____

Note: Items that do not apply enter N/A in the blank.

**RECORD CONTINUOUS MONITORING RESULTS EVERY 2 HOURS
CONTINUOUS MONITORING**	Permissible	___________________________
TEST(S) TO BE TAKEN	Entry Level
PERCENT OF OXYGEN	19.5% to 23.5%	___ ___ ___ ___ ___ ___ ___ ___
LOWER FLAMMABLE LIMIT	Under 10%	___ ___ ___ ___ ___ ___ ___ ___
CARBON MONOXIDE	+35 PPM	___ ___ ___ ___ ___ ___ ___ ___
Aromatic Hydrocarbon	+ 1 PPM  *   5PPM	___ ___ ___ ___ ___ ___ ___ ___
Hydrogen Cyanide	(Skin)      *   4PPM	___ ___ ___ ___ ___ ___ ___ ___
Hydrogen Sulfide	+10 PPM * 15PPM	___ ___ ___ ___ ___ ___ ___ ___
Sulfur Dioxide	+ 2 PPM  *   5PPM	___ ___ ___ ___ ___ ___ ___ ___
Ammonia	* 35PPM	___ ___ ___ ___ ___ ___ ___ ___

* Short-term exposure limit: Employee can work in the area up to 15 minutes.
+ 8 hr. Time Weighted Avg.: Employee can work in area 8 hrs (longer with appropriate respiratory protection).
REMARKS:_____________________________________________________________

GAS TESTER NAME	INSTRUMENT(S)	MODEL	SERIAL &/OR
& CHECK #	USED	&/OR TYPE	UNIT #
________________	________________	________________	________________
________________	________________	________________	________________

SAFETY STANDBY PERSON(S)	CHECK #	CONFINED SPACE ENTRANT(S)	CHECK #	CONFINED SPACE ENTRANT(S)	CHECK #
______________	______________	______________	______________	______________	______________
______________	______________	______________	______________	______________	______________

SUPERVISOR AUTHORIZING - ALL CONDITIONS SATISFIED____________________
	DEPARTMENT/PHONE ___________________________

AMBULANCE 2800  FIRE 2900  Safety 4901  Gas Coordinator 4529/5387

[58 FR 4549, Jan. 14, 1993; 58 FR 34846, June 29, 1993]