CONFINED SPACE PERMIT #

Confined Space Entry Permit

GENERAL INFORMATION POTENTIAL HAZARDS
Identification of any hazards to be
Space Description: controlled/eliminated by this permit
See Written Entry Plan for details
Location: Hazardous Atmosphere
High Oxygen Low Oxygen
Purpose of Entry: Toxic Flammable
Combustible Dust Irritant Dust
Rescue Service Providers: On-Site (Must Be Checked) Physical Hazard
OFF SITE EMERGENCY MEDICAL SERVICES (NOT RESCUERS) Live Line Hazard
NAME OF SERVICE PHONE Work Activity Hazard Perimeter Hazard
Other ______________________________

REQUIREMENTS FOR ENTRY OTHER WORK RESTRICTIONS AND REQUIREMENTS

Check applicable line, then check specific items Check applicable line, then check specific items
Attendant Visually Identified Respiratory Protection
Forced Air Ventilation Supplied Air with ___ Min Egress Cylinder Breathing Air Compressor SCBA
Set Up: Exhaust Pos. Pressure Both Air Supplied Hood* Air Purifying Mask with Cartridge* Type:
Power: Air Electrical Other _______ IDLH Compressed Air Quality Check Other:
Other: _______________________ Personal Protective Equipment (Attach MSDS)
Atmosphere Testing Impact Goggles Face Shield Chemical Suit Chemical Hood
Periodic for: ______________ Chemical Goggles Chemical Apron Chemical Gloves Rubber Boots
Continuous for: _______________ Fall Protection Hearing Protection
Communications with Entrants Other: _________________________________________________________
Voice Radio Visual Safety Equipment and Monitors
Other ______________________________ Fire Extinguisher Fire Watch Personal Atmosphere Monitors
Rescue Equipment (At/Near Entry Point) Other: _____________________________________________________________
Lifeline Harness Tripod/A-frame Hazardous Work Allowed (Only the Work Types Checked Are Approved)
Rescue Plan Hot Work: Welding Cutting Brazing Other Ignition Source (i.e., Grinding)
Respiratory Equipment Electrical Radiography Abrasive Blasting Hydro-Blasting
Other ______________________________ Other: _________________________________________________________
Other Tools, Equipment & Supplies (Only the Following Are Approved)
Signs Barriers Barricades Hand Tools Pneumatic Tools Arc Welder – inspected and properly grounded
Lighting: Low Voltage 110V GFCI Torch Internal Combustion Engine Lifting Devices Non-Sparking Tools
Ladders Non-metal Ladder GFCI Protected Electrical Tools, Lighting and Utilities
Other ______________________________ Other:
________________________________________ Other __________________________________________________________
________________________________________ ____________________________________________________________________________
*Not Acceptable for Use in Oxygen Deficient Atmospheres
PRE-ENTRY MEETING BY ENTRY SUPERVISOR
Verified That Attendants/Entrants/Rescuers CS Entry Trained Mandatory, Daily Pre-Entry Meeting
Reviewed Safety Work Permit and Confined Space Entry Permit When to Notify Entry Supervisor
Written Entry Plan Reviewed Entry Supervisor Is the Only Person to Authorize Entrants
Written Rescue Plan Reviewed (Attached) Confined Space Danger Signs Posted
Establish Confined Space Entry Condition Log (Attach) Respirator Training & Clearance, As Required
Establish Confined Space Entrant/Attendant Log (Attach) Hazard Communication Info and Other Potential Hazards Covered
Procedures and Equipment Specifications Pre-Entry Meeting Log Completed - (Attach)
Review the operation of the atmospheric monitor, min & max allowable Welding Safety Plan Completed - (Attach)
levels, alarms

Rescue Drill completed (document learnings, if any, on reverse)

ISSUED BY: Entry Supervisor signature - Boxes Pre-entry Safety Work
marked w/ NA or left blank: The Entry Supervisor certifies that Mtg. Issued Valid Until Permit(s) #
these items were considered and are not required or applicable Must Be
IDLH Entry? (Requires 2 signatures) Checked Date Time Date Time

PERMIT CLOSE OUT Closed - Entry Operations Completed Closed – Entry Operations Completed/Stopped - Problems were
Indicate one at the and No problems were encountered encountered, which required entry work to be halted or suspended. Indicate
completion of entry new permit number, if work resumed under a new Entry Permit:____________
operations: Debrief Entry team members. Use reverse of this sheet or additional pages to describe any problems encountered,
record positive feedback and/or improvement suggestions.

Permit Closed by: _______________________________________________ Date/Time: ______________________________________

25-010533h Rev. 0 FORM 2026-4 (03/2022) PLEASE PRESS HARD