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Subchapter 7. General Industry Safety Orders
Group 16. Control of Hazardous Substances
Article 108. Confined Spaces

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§5157. Permit-Required Confined Spaces, Appendix D-2. Entry Permit


                           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


NOTE: Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code.

HISTORY

1. New Appendix D filed 11-24-93; operative 12-24-93 (Register 93, No. 48).

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