CONFINED SPACE ENTRY PERMIT

Project: Site:
Date/Time of Entry: Permit Expires:
Location of Confined Space: Contractor:
Tank: Pipe: Manhole: Tunnel: Vault: Other:
Work Description/Purpose of Entry:

Verification: Date Supervisor’s Signature

Tagout/Lockout (electrical, agitators, valves)
Purged, Cleaned, and Drained
Employees Briefed on Safety Procedures

Mandatory? Mandatory?
Special Requirements: Yes No Yes No
Notify Plant Control Room Fire Extinguisher
B&V Safety Department Notified Y N/A Lifelines
Adequate Access Y N/A Harness, Safety Belt
Lighting Adequate (low voltage) Respirators
Attendant Required Outside Air Supplied Respirator
Warning Signs Posted at Access Y N/A Protective Clothing
Ventilation Required Radio Communication
Personnel Entry/Exit Log at Access Signaling Air Horns
Rescue Equipment at Access Point Y N/A Tripod Emergency Escape Unit
Daily Monitoring Employee Training/Indoctrination Y N/A
(include T/I record on back)
Other Requirements:

Atmosphere Check for Oxygen, Combustibles, and Gas/Vapor

Instrument Type:
Atmosphere Checked By:

Pre-entry
Reading a.m. a.m. Permissible Exposure Level
Oxygen 19.5% to 23.5%
Combustible Gases 10.0% or less
Toxic Gases CO + 35 ppm, SO2 2 ppm, H2S 10 ppm
In case of emergency, call:

The following authorizing signatures indicate the above requirements have been met:
Superintendent in Charge of Work: Date:
Foreman in Charge of Work: Date:
Attendant: Date:
Permit Issued By: Date:

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 Initial/Time Initial/Time

Authorized Entrants (please print name) In Out Authorized Entrants (please print name) In Out

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 CONFINED SPACE ENTRY PERMIT

TRAINING/INDOCTRINATION RECORD

Site: Contractor:

Items/Subject Matter Covered/Included:

Your Emergency Communication Device is:

Your Emergency Communication Device is located:

Your Confined Space Entry Supervisor is:

Printed Name Signature Date

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 RECOMMENDATIONS FOR SAFE ENTRY: A CHECKLIST

Use the following checklist to evaluate the confined space.

Do not enter a confined space until you have considered every question and have determined the
space to be safe.

YES NO
Is entry necessary?

TESTING
Are the instruments used in atmospheric testing properly calibrated?
Was the atmosphere in the confined space tested?
Was the oxygen at least 19.5 percent - not more than 23.5 percent?
Were toxic, flammable, or oxygen-displacing gases/vapors present?
-Hydrogen Sulfide
-Carbon Monoxide
-Methane
-Carbon Dioxide
-Other (list)

MONITORING
Will the atmosphere in the space be monitored while work is going on?
Continuously?
Periodically? (If yes, give interval: )
Remember – Atmospheric changes may occur due to the work procedure or the product
stored.

CLEANING
Has the space been cleaned before entry is made?
Was the space steamed?
If so, was it allowed to cool?

VENTILATION
Has the space been ventilated before entry?
Will ventilation be continued during entry?
Is the air intake for the ventilation system located in an area that is free of combustible dusts and
vapors and toxic substances?
If atmosphere was found unacceptable and then ventilated, was it retested before entry?

ISOLATION
Has the space been isolated from other systems?
Has electrical equipment been locked out?
Have disconnects been used where possible?
Has mechanical equipment been blocked, chocked, and disengaged where necessary?
Have lines under pressure been blanked and bled?

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YES NO
CLOTHING/EQUIPMENT
Is special clothing required (boots, chemical suits, glasses, etc.)?
(If so, specify: )
Is special equipment required (rescue equipment, respirators, communications equipment, etc.)?
(If so, specify: )
Are special tools required (sparkproof)?
(If so, specify type: )

RESPIRATORY PROTECTION
Are MSHA/NIOSH-approved respirators of the type required available at the worksite?
Is respiratory protection required (air-purifying, supplied air, self-contained breathing apparatus,
etc.)?
(If so, specify: )

TRAINING
Have you been trained in proper use of a respirator?
Have you received first aid/CPR training?
Have you been trained in confined space entry and do you know what to look for?

STANDBY/RESCUE
Will there be a standby person on the outside in constant visual or auditory communication with
the person on the inside?
Will the standby person be able to see and/or hear the person inside at all times?
Has the standby person(s) been trained in rescue procedures?
Will safety lines and harness be required to remove a person?
Are company rescue procedures available and can they be followed in the event of an
emergency?
Are you familiar with emergency rescue procedures?
Do you know who to notify and what to do in the event of an emergency?

PERMIT
(The permit is an authorization in writing that states that the space has been tested by a qualified
person; that the space is safe for entry; what precautions, equipment, etc., are required; and what
work is to be done.)
Has a confined space entry permit been issued?
Does the permit include a list of emergency telephone numbers?

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 PERMIT-REQUIRED CONFINED SPACE DECISION FLOW CHART

Does the workplace contain permit-required NO Consult other applicable

confined spaces as defined by §1910.146(b)? OSHA standards
YES STOP
Inform employees as required by §1910.146(c)(2).

NO Prevent employee entry as required by

Will permit spaces be entered?
§1910.146(c)(3). Do task from outside of space.
YES
YES Task will be done by contractors’ employees. Inform contractor as
Will contractors enter?
required by §1910.146(c)(8) (i), (ii), and (iii). Contractor obtains
NO information required by §1910.146(c)(9)(i), (ii), and (iii) from host.

Both contractors and host NO

Will host employees enter to NO
perform entry tasks?
YES
Prevent unauthorized
entry.
employees will enter the space?
YES
Coordinate entry operations as required
by §1910.146(c)(8)(iv) and (d)(11).
STOP
Prevent unauthorized entry.

Does space have known or NO Not a permit-required confined space. §1910.146

potential hazards? does not apply. Consult other OSHA standards.
YES
YES Employer may choose to reclassify space to non permit- STOP 1
Can the hazards be eliminated?
required confined space using §1910.146(c)(7).
NO
Can the space be maintained in a condition safe YES Space may be entered under STOP 1
to enter by continuous forced air ventilation only? §1910.146(c)(5).
NO
Prepare for entry via permit procedures.

Verify acceptable entry conditions (test results recorded, Permit not valid until
NO
space isolated if needed, rescuer/means to summon conditions meet
available, entrants properly equipped, etc.) permit specifications.

YES
Permit issued by authorizing signature. Acceptable entry
conditions maintained throughout entry.
YES
Entry tasks completed. Permit returned and cancelled.
Audit permit program and permit based on evaluation of
entry by entrants, attendants, testers, and preparers, etc.
NO Emergency exists (prohibited condition).
Extrants evacuated entry aborts. (Call
rescuers if needed.) Permit is void.
Reevaluate program to correct/prevent
prohibited condition. Occurrence of
emergency (usually) is proof of deficient
program. No re-entry until program
(and permit) is amended. (May require
new program.)

1Spaces may have to be evacuated and reevaluated if hazards

arise during entry. CONTINUED

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