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Confined/Enclosed Space Entry Permit



 
 
 

Requirements Checklist (check all that apply)

 
 Full body harness  Tripod / hoist
 Leather  Impervious  Other:
 
 Warning signs  Barricades
 Ladder
 Fall protection equipment
 Ventilation fan or blower
 Fire extinguisher
 Air purifying respirator: specify cartridge type:
 Other:
 Face shield  Goggles
 Footwear
 Coveralls
 Head protection
 First Aid Kit
 Cell Phone/Radio for Emergency Communication
 

Pre-entry Checklist

 Verify adequate confined space training
 Pre-entry briefing on specific hazards and control methods
 Non-entry rescue and procedure in place
 Notify affected departments and persons of service interruption
 Lines blocked or broken
 Drain space
 Other:
 Lockout / tagout (LOTO)
 Zero-voltage verification (ZVV)
 Other:
 
 Radio
 Hand signals
 Verbal
 Hazardous location rated
 Standard
 
 Preliminary
 Continuous
 Other
 
 

Air Monitoring Results (to be completed as needed before and during work)

Attendant will sample air
 Continuously
 Every  
 
Device
Serial number
Calibration due date
Checked by
Notes
 
Date:
 
Time
Initial Readings:
Sampled by initials:
 O2(19.5–23.5%)
 (LEL/LFL <10%)
 CO(<25 ppm)
 H2S(<10 ppm)
 

Pre-entry Certification (must be signed by the confined space entry supervisor before entry)

I hereby certify that all required hazard controls are in place, that air monitoring is being conducted as required and results show that the atmosphere is acceptable for entry, and that all required information is documented on this permit.

 
 clear signature
 

Permit Closure (must be signed by the confined space entry supervisor after work is completed)

The work was done in accordance with this permit. A copy of this permit will be forwarded to the H.B. Frazer Safety Director for Recordkeeping.

 
 clear signature