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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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