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// CODE SNIPPET

Appendix D Confined Space Pre-Entry Check List

OSHA 1910 General Industry > J General Environmental Controls > 1910.146 Permit-Required Confined Spaces > D Confined Space Pre-Entry Check List
JUMP TO FULL CODE CHAPTER
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

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 ____ ____
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 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
Confined Space Entry Permit Date and Time Issued: _________________ Date and Time Expires: _________ Job site/Space I.D ...
OSHA 1910 General Industry > J General Environmental Controls > 1910.146 Permit-Required Confined Spaces > D Confined Space Pre-Entry Check List
1910.146(j) General Environmental Controls, Duties of Entry Supervisors
; Verifies, by checking that the appropriate entries have ...
OSHA 1910 General Industry > J General Environmental Controls > 1910.146 Permit-Required Confined Spaces > 1910.146(j) Duties of Entry Supervisors
1910.146(c)(5)(ii)(H) General Environmental Controls,
The employer shall verify that the space is safe for entry and that the pre-entry measures required by paragraph (c)(5)(ii) of this section have been ...
OSHA 1910 General Industry > J General Environmental Controls > 1910.146 Permit-Required Confined Spaces > 1910.146(c) General Requirements > 1910.146(c)(5) > 1910.146(c)(5)(ii) > 1910.146(c)(5)(ii)(H)
1910.146(e)(3) General Environmental Controls,
it at the entry portal or by any other equally effective means, so that the entrants can confirm that pre-entry preparations have been completed ...
OSHA 1910 General Industry > J General Environmental Controls > 1910.146 Permit-Required Confined Spaces > 1910.146(e) Permit System > 1910.146(e)(3)
1910.146(e) General Environmental Controls, Permit System
representatives, by posting it at the entry portal or by any other equally effective means, so that the entrants can confirm that pre-entry preparations have been ...
OSHA 1910 General Industry > J General Environmental Controls > 1910.146 Permit-Required Confined Spaces > 1910.146(e) Permit System
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