Permit Number_______________

Confined Space Entry Permit

Rescue #______________ Gas Coordinator #_______________ Emergency Services #_______________

Company Name: __________________________ Date & Time Issued: ______________________________

Job Site / Space ID: __________________________ Date & Time Expires: ______________________________
Purpose of Entry:
HAZARDS IN THE CONFINED SPACE: () REQUIRED ENTRY EQUIPMENT: ()
 Oxygen deficiency (<19.5%)  Respirator COMMUNICATION
 Toxic gasses or vapors > PEL  Coveralls  Line of sight
 Engulfment or Entrapment (circle selections)  Hearing protection  Radios
 Electrical hazards  Explosive proof lighting  Other _____________
 Flammable hazards (gasses, vapors, high oxygen)  Fire Extinguishers ADDITIONAL NOTES
 Heat or Cold (circle one)  Harnesses
 Hazardous configuration  Emergency Escape Equipment
 Rotating or moving equipment  Resuscitator - Inhalator
 Chemical hazards  Emergency Escape Respirator
 Other ___________________________________  Other: ____________________
AUTHORIZED WORKERS Written Rescue Plan Posted
Entrants: _________________________________________  Employee Rescue
Attendants: _________________________________________  Employee Non Entry Rescue
Supervisors: _________________________________________  Outside Rescue – Contact #______________
Acceptable Entry Conditions: ______________________________________________________________________________
ENTRY PREPARATIONS  Review hazards and work procedure ATMOSPHERIC TESTING
 Notify affected employees of work  Notify available emergency team Test will be done before entry
 Isolate hazardous energy  Atmospheric test satisfactory Continuous monitoring? Yes No
 Apply locks and tags  Additional permits obtained Test frequency: ____________________
 Verify isolation  Required PPE worn Tester name: ____________________
 Secure area with posts and flags  Communication plan works Tester ID #: ____________________
 Clean, drain and purge space  Other ________________________ Tester name: ____________________
 Establish required ventilation  Other Tester ID:
TEST PEL  1 2 3 4 5 6 7 8
O2 Min 19.5% 
O2 Max 23.5% 
Flammability 10% LFL 
Carbon Monoxide 35 ppm 
H2S 10 ppm 
Sulfur Dioxide 2 pm 
Toxic 
Temperature 
Other 
Other 
Instrument #1 Model / Type ID Number
Instrument #2 Model / Type ID Number
Notes:
AUTHORIZATION Time: Name: ______________________________
I certify required entry conditions are met Date:
Signature: ______________________________
& it is safe to commence work in this space. Phone:
Notes:

Date / Time Work Complete: ___________ Work Verified By: __________________ Permit Closed 