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CONFINE SPACE ENTRY ASSESSMENT FORM ee eee SPACE NAME fw 2 ‘PACKAGE NBL _PPotect ne a eae aan aint [firemmer__| tPF _ = a a CSRECISTERNUMDER | ~ SE Ee tet [orem ‘want [Nvanmnat co |] 0 [cnarons | GE xaM eo [1s | vo |somerome nT my BE CONDUCTED AND SIGHED OFF HY TWO CSE QUAMTED PERSIE pave | [nme nee KSPR CONFINED SPR TE HTLOWINE UESTIONS TS SYS 86 {Lethe space encosed or partially encosed? y capa seertmaniaty oll »~ | © ote -a person may regulary etraspaetn perform work th des ot hake he space a prmal pee work —FRD =AS THESPACE ABLE AT ANT TIMETO WAVE? TA. amaumosper that oes otbave asafeceyen evel (ate oxygen eel An ampsrygen coment nar of between 19.5% ~ 285%) rel (tse njry frm Bre o explosion. TE parmfl onccatratons af any aborne contaminants ve —Tammns wrcanpeaitanepesvapossneaumniarmy | ve | @ © © pune poem hat may cause esationo drowning (SOs of eetiowingsold oF sing Qu) rei baa yor To Tan pasa yesunatleantons rh B.COFD. © ves TS THE AREA A CONFINED SPACE TST ATH NEDIT SNOT ACONFNED SPACE QUALIFIED COMPETENT [ERSON SHALL REVIEW AND SIGN) name | Mun tant [sawrime | AC [oars [20 Tor bev \ \@us &

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