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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 - Confined Space Entry Permit.

Appendix D-1


Confined Space Entry Permit
Date and Time Issued: _______________ Date and Time Expires: ________
Job site/Space I.D.: ________________ Job Supervisor:________________
Equipment to be worked on: __________ Work to be performed: _________

Stand-by personnel: __________________ ________________ _____________

1. Atmospheric Checks:   Time      ________
                         Oxygen    ________%
                         Explosive ________% L.F.L.
                         Toxic     ________PPM
2. Tester's signature: _____________________________
3. Source isolation (No Entry):  N/A   Yes   No
     Pumps or lines blinded,     ( )   ( )   ( )
     disconnected, or blocked    ( )   ( )   ( )
4. Ventilation Modification:     N/A   Yes   No
     Mechanical                  ( )   ( )   ( )
     Natural Ventilation only    ( )   ( )   ( )
5. Atmospheric check after
   isolation and Ventilation:
     Oxygen __________%           >    19.5   %
     Explosive _______% L.F.L     <    10     %
     Toxic ___________PPM         <    10     PPM H(2)S
     Time ____________
     Testers signature: _____________________________
6.  Communication procedures: _______________________________________
_____________________________________________________________________
7.  Rescue procedures: ______________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
8. Entry, standby, and back up persons:      Yes       No
   Successfully completed required
     training?
   Is it current?                            ( )       ( )
9. Equipment:                           N/A       Yes       No
   Direct reading gas monitor -
     tested                             ( )       ( )       ( )
   Safety harnesses and lifelines
     for entry and standby persons      ( )       ( )       ( )
   Hoisting equipment                   ( )       ( )       ( )
   Powered communications               ( )       ( )       ( )
   SCBA's for entry and standby
     persons                            ( )       ( )       ( )
   Protective Clothing                  ( )       ( )       ( )
   All electric equipment listed
     Class I, Division I, Group D
     and Non-sparking tools             ( )       ( )       ( )

10.  Periodic atmospheric tests:
      Oxygen    ____%  Time ____  Oxygen    ____%  Time ____
      Oxygen    ____%  Time ____  Oxygen    ____%  Time ____
      Explosive ____%  Time ____  Explosive ____%  Time ____
      Explosive ____%  Time ____  Explosive ____%  Time ____
      Toxic     ____%  Time ____  Toxic     ____%  Time ____
      Toxic     ____%  Time ____  Toxic     ____%  Time ____

We have reviewed the work authorized by this permit and the
information contained here-in. Written instructions and safety
procedures have been received and are understood. Entry cannot be
approved if any squares are marked in the "No" column. This permit is
not valid unless all appropriate items are completed.

Permit Prepared By: (Supervisor)________________________
Approved By: (Unit Supervisor)_______________________________________
Reviewed By (Cs Operations Personnel) :
________________________________________   __________________________
       (printed name)                             (signature)

This permit to be kept at job site. Return job site copy to Safety
Office following job completion.

Copies:   White Original (Safety Office)
          Yellow (Unit Supervisor)
          Hard(Job site)

Appendix D - 2

                           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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