CONFINED SPACE ENTRY PERMIT

Date:

Tank #:

Name Time In Time Out S i g n a t u r e ( u p o n c o m p l e ti o n o f t a s k ]

Entrant:

Attendant:

Work to be performed

HAZARDS
- Space may contain low levels of oxygen (U2) / high levels of carbon dioxid e (LU2)
- P OT E N T I A L LY H A Z A R D O U S AT M O S P H E R E M U S T B E T E S T E D A N D R E C O R D ED ON PE RM IT PRI OR TO E N T R Y
- Symptoms of CO2 toxicity include; dizzi ness, hea dache, nausea, vomiti ng, rapid breathing/heart i ate,
confusion, loss of consciousness, death
- E ngulf m ent
- Slips, trips, and falls

Required Equipment

Direct reading 02 gas monitor

Safety harness and lifelines for all entrants

Periodic atmospheric tests:

Acceptable Entry Conditions: 02 > 19.5%

Before Entry:

7,O2
IF 02 ALARM GOES OFF AT ANY TIM E
ENTRANT MUST LEAVE THE SPACE
IMMEDIATELY!!!

1S min:

%02

3
0
m
i
n
: