// CODE SNIPPET
Appendix D Confined Space Pre-Entry Check List
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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: __________________ ________________ _____________
2. Tester's signature: _____________________________
6. Communication procedures: ________________________________________ _____________________________________________________________________
7. Rescue procedures: _______________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________
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)__________________________________________
This permit to be kept at job site. Return job site copy to Safety
Office following job completion.
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*
Note: Items that do not apply enter N/A in the blank.
* 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:_____________________________________________________________
AMBULANCE 2800 FIRE 2900 Safety 4901 Gas Coordinator 4529/5387
[58 FR 4549, Jan. 14, 1993; 58 FR 34846, June 29, 1993]
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 ____ |
Permit Prepared By: (Supervisor)________________________________________
Approved By: (Unit Supervisor)__________________________________________
Reviewed By (Cs Operations Personnel) : | |
_________________________________ | _________________________________ |
(printed name) | (signature) |
Copies: | White Original (Safety Office) |
Yellow (Unit Supervisor) | |
Hard(Job site) |
Appendix D - 2
ENTRY PERMIT
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 | ____ | ____ |
**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 IS REQUIRED FOR ALL CONFINED SPACE WORK
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]
Related Code Sections
Appendix D General Environmental Controls, Confined Space Pre-Entry Check List
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