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Subchapter 7. General Industry Safety Orders
Group 16. Control of Hazardous Substances
Article 108. Confined Spaces
Group 16. Control of Hazardous Substances
Article 108. Confined Spaces
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§5157. Permit-Required Confined Spaces, Appendix D-1. Confined Space Entry Permit
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)
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