Confined Space Program
Entry Permit A- General Work
(Check or fill in all blanks that apply)
Today’s Date ___________________
Time of Entry Date ____________ Time ____________ Safety Permit No. _________________
Purpose of Entry Inspection p Cleaning p Maintenance p Repair p Hot Work p
* If "Hot Work" is checked, use Hot Work Permit.
Other _______________________________________________________________
Brief Description of Purpose _______________________________________________________________
Location of Entry (Be Specific)
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Have all personnel gone through a pre-entry briefing? Yes p No p
Space tested by (Name & Title) ____________________________________________________________
Sampling Equip-Model ____________ S/N ____________ Calibration Date __________
Pre-entry reading taken? Yes p No p If no, why not?__________________________
% Oxygen: Opening _________ Middle _________ Bottom _________ Other _________
* All > 19.5% by volume and < 21.5% by volume
% of LEL: Opening _________ Middle _________ Bottom _________ Other _________
* All < 10% LEL
Toxic Reading- CO _________ H2S _________ Other _________
* All <PEL (Additional readings below)
Are all power sources intrinsically safe? Yes p No p
Have personnel been given the proper PPE? Yes p No p
Is an attendant posted and all trained to work safely and use equipment? Yes p No p
Is a rescue plan in place? Yes p No p
Has area been secured and all energy sources locked and tagged? Yes p No p
Is there any possibility of entrapment or engulfment by particular matter? Yes p No p
If yes, has provision been made to work safely in such an area? Yes p No p
Are entry personnel in lifeline and harness? Yes p No p
Specify communication devices to be used ___________________________________________________
Comments __________________________________________________________________________
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I certify the above conditions are accurate and validate the entry for the stated purpose, time and identified employees not to exceed the work for one shift. If any question was answered no and satisfactory answer was not given, do not issue permit.
Entry supervisor’s name (print) _________________________________Date______________
Signature _____________________________ Title__________________________________
Shop or Area _________________________