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Confined Space Permit Confined Space Pre-Entry Assessment Equipment to be worked on: Purpose of Entry: Person originating assessment: Date: Time: Pre-Entry Atmosphere Check by (Name): Date: Time: Oxygen > 19.5% and < 23.5% % LEL: < 10% LEL (Pentane) % Test Meter Information CO: < 35 ppm ppm Make: Model: Serial: H2S: < 10 ppm ppm SO2: < 2 ppm ppm Toxics: Confined Space Hazards At Time of Entry 1. Does this space contain or have the potential to contain a hazardous atmosphere? Yes No - Flammable gases or vapors? Yes No - Dusts that can reach concentrations to be explosive? Yes No - Oxygen levels below 19.5% or above 23.5%? Yes No - Any other condition that is immediately dangerous to life and health. Yes No 2. Does this space contain a material that has the potential for engulfing an Entrant? Yes No 3. Does this space have an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or floor? Yes No 4. Does this space contain any other recognized serious safety and health hazards? Yes No 5. Will ventilation be required to remove or eliminate the hazards during the entry? Yes No If any boxes are checked “Yes”, then this is a Hazardous Confined Space and rescue planning is required Describe the methods used to remove the hazards, including Lock Out/Tag Out, Sampling, etc. Lock Out/Tag Out: Other Methods Used: 1. Is continuous monitoring to be used? Yes No 2. Is continuous ventilation to be used Yes No If “No”, why Circle One: Non-Hazardous Space Hazardous Space – (Additional requirements) Supervisor Approval For Entry: Date: Note: Completed form should be displayed at entry point and forwarded to EH&S after work is complete.
