This certification form is to be completed for authority to allow entry in a permit required confined space which is being temporarily reclassified as a non-permit confined space. It may only be issued under the conditions set forth in the written entry procedures specific to the space identified on this form.

NO WORK MAY BE PERFORMED WITHIN THIS SPACE THAT MAY PRODUCE HAZARDS OF UNACCEPTABLE LIMITS.

This certification shall be made available to each employee entering the space.

Specific location and space:____________________________
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Date entry is authorized: ________________

Time effective:         From: _____________ To: _____________

Describe each specific step taken as prescribed by the written entry procedure as basis for determining all hazards have been eliminated (i.e. lockout-tagout of feed valves or power switches, atmosphere depressurized, removal of contaminants, temperature adjustment, etc.)
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Person making determination that all hazards have been eliminated:

_________________________ _________________________
print name                                     signature

_______________ ______________
 date verified             time verified