Location and Description

of Confined Space Date

Purpose of entry Time

Department Expiration date/time

NATURE OF HAZARDS (Check)

Oxygen deficiency (<19.5%) Mechanical hazards

Flammable gases or vapors Electrical hazards

(>10% of lower flammable limit, Engulfment

or >23.5% oxygen) Materials harmful to skin

Toxic gases or vapors Other (specify)

(>permissible exposure limit)

PRELIMINARY (Check) EQUIPMENT REQUIRED (Check)

Affected Depts. notified Respirator (Specify type)

Isolated, Locked/Tagged Lifeline and safety harness

Drained, cleaned, purged Protective clothing

Ventilated Fire Protection

Barricades erected Electrical equipment & tools:

Procedure reviewed w/ employees Low voltage

Employees informed of hazards Explosion proof

Atmospheric test in compliance Ground fault circuit interrupters

Other Approved for hazardous location

Communication aid (specify):

HOT WORK

Burning Welding Soldering

Cutting Heating Permit Obtained? Yes No

Allowable Check if Time & Time & Time &

TESTS Limits Required Results Results Results

Oxygen-min 19.5%

Oxygen-max 23.5%

H2S 10 ppm

Cl2 0.5 ppm

SO2 0.2 ppm

CO 35 ppm

Flammability 10% LEL

Other

Other

Other

Atmospheric monitoring conducted by