PERMIT-REQUIRED CONFINED SPACE

1

• PERMIT-REQUIRED CONFINED SPACE

Location of Confined Space Space
Number Trade Shop Purpose of
Entry Authorized Duration of Permit
Date to
Time to Additional
Permits (circle all that apply) Burning Welding B
razing Cutting Open Flame POSSIBLE HAZARDS
PRESENT (circle all that apply) Oxygen
deficiency Electrical shock Oxygen
enrichment Engulfment Combustible
dust Pressurized Systems Materials harmful
to skin Flammable gases or vapors Toxic gases or
vapors Mechanical hazards OTHER (please
describe) HOW ARE HAZARDS BEING ELIMINATED
BEFORE ENTRY (circle all that apply) Lockout/Tago
ut Disconnecting(blanking) Cleaning Forced
Air Ventilation OTHER (please describe) EMERG
ENCY SERVICE USC POLICE DEPARTMENT TELEPHONE 7-
9111 AUTHORIZATIONS Authorized Entry
Employees Authorized Attendant Authorized
Entry Supervisor I certify that all required
precautions have been taken and
necessary equipment is provided for safe entry
and work in the above listed confined
space. Name(print)
Signature Date
EHS-F-014 Page 1 Issue Date 7/8/03
Destroy Previous Revisions Approved
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2

• I
• INITIAL GAS CHECKS - BEFORE VENTILATION IS
  APPLIED
• Oxygen- Top Middle Bottom Must be
  between 19.5-23.5
• LEL - Top Middle Bottom Must be less
  than 10
• CO ppm- Top Middle Bottom Must be less
  than 35 ppm
• H2S ppm- Top Middle Bottom Must be less
  than 10 ppm
• PERIODIC ATMOSPHERIC TEST RESULTS
• Is forced air ventilation being applied?
  (circle) YES NO
• Instrument reading must be Oxygen between
  19.5 and 23.5
• LEL lower
  than 10
• CO ppm lower
  than 35 ppm
• H2S ppm
  lower than 10 ppm

Initial
Time
Oxygen
LEL
CO ppm
H2S ppm
Comments























































































































EHS-F-014 Page 2 Issue Date 7/8/03
Destroy Previous Revisions Approved
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3

• SIGNATURE FORM FOR ENTERING A CONFINED SPACE
• This form must be used any time a Confined Space
  Entry Permit is used.
• The observer/attendent must keep this form at the
  entrance of the Confined Space.
• Each person who enters and exists the Confined
  Space must sign and record the time on this form.
• If a person exits the Confined Space in a
  location other than where the observer is
  located, he must
• immediately report and sign this form.
• Name Time IN Time OUT Signature

EHS-F-014 Page 3 Issue Date 7/8/03
Destroy Previous Revisions Approved
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