Occupational Safety and Health Standards: General Environmental Controls, Confined Space Pre-Entry Check List

If you are the victim of construction accidents, use this page to conduct research. To have your case evaluated immediately, please fill out our form. Read more about the Occupational Safety and Health Standards, 1910.146 App D, General Environmental Controls, Confined Space Pre-Entry Check List.

Appendix D to 1910.146 -- Sample Permits

Appendix D-1

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 ________% L.F.L.

Toxic ________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 CHECK # CONFINED CONFINED

PERSON(S) SPACE CHECK # SPACE CHECK #

ENTRANT(S) ENTRANT(S)

______________ _______ __________ _______ __________ _______

______________ _______ __________ _______ __________ _______

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]

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