Permit-Required Confined Space Entry

Per 29 CFR 1910.146. Space must be tested and continuously monitored. Attendant must remain outside. Rescue must be pre-arranged and reachable.

0/14 pre-entry checks

1Space Identification

Permit #

Date

Valid From

Valid To

Space Name / ID

Location

Space Description

Purpose of Entry

2Identified Hazards

Oxygen deficiency (< 19.5%)Oxygen enrichment (> 23.5%)Flammable atmosphere (> 10% LEL)Toxic atmosphere (CO, H₂S, NH₃, etc.)Engulfment by liquid or granular materialEntrapment / inwardly converging wallsThermal (heat stress / cold)Mechanical / moving partsElectrical (shock, arc flash)Noise (> 85 dBA)Chemical (dermal, inhalation)Physical (slips, falls, poor lighting)Biological (sewage, mold, pathogens)Radiation

3Atmospheric Testing — Initial & Continuous

Test order per 1910.146(d)(5)(i): Oxygen first, then flammables, then toxics. Calibrate and bump-test the meter before every shift.

ParameterReadingAcceptable RangeTime

Oxygen

19.5 – 23.5%

Flammables

< 10%

Carbon Monoxide

< 35 ppm

Hydrogen Sulfide

< 10 ppm

Other (specify)

PEL

Retest Frequency

4Entry Team

Entry Supervisor

Attendant (outside)

Authorized Entrants

5Rescue & Communication

Rescue Type

Rescue Team / Contact

Response ETA

Communication Method

Emergency Signal

6Pre-Entry Safety Verification

1.Lines/pipes isolated (blinds, double block & bleed, or LOTO)

2.Mechanical equipment locked out and tagged out

3.Electrical isolation verified (LOTO)

4.Space cleaned/purged of hazardous material

5.Continuous mechanical ventilation in place

6.Atmospheric monitoring equipment calibrated (bump-tested today)

7.Communication method established (radio, voice, signal rope)

8.Retrieval equipment (tripod, winch, body harness) in place

9.Rescue team notified and on standby / response time confirmed

10.PPE selected and worn (hard hat, eye/face, respiratory, gloves, fall arrest)

11.Lighting adequate (intrinsically safe in hazardous atmospheres)

12.Entrants, attendant, supervisor trained and qualified

13.Entry supervisor has reviewed this permit

14.Atmospheric test results within acceptable limits (below)

7Special Procedures / Notes

Additional Notes

8Permit Cancellation (complete when work ends)

Cancellation Reason

Cancellation Time

Read: Confined Spaces guide