AL THAIL GROUP OF COMPANIES
CONFINED SPACE ENTRY
CONFINED SPACE LOCATION / DESCRIPTION:
PURPOSE OF ENTRY:
TIME IN: TIME OUT:
STAND BY PERSON:
HAZARDS OF CONFINED SPACE YES NO SPECIAL REQUIREMENTS YES NO N/A
OXYGEN DEFICIENCY LOCK OUT / TAG OUT
COMBUSTABLE GAS/ VAPOR VENTILATION
COMBUSTABLE DUST BREATHING APPARATUS
CARBON MONOXIDE LIFELINES
HYDROGEN SULFIDE LIGHTING
TOXIC GAS/ VAPOR PPE (GOGGLES, GLOVES, CLOTHING ETC)
TOXIC FUMES HOT WORK PERMIT REQUIRED
SKIN CHEMICAL HAZARDS FIRE EXTINGUISHER
ELECTRICAL HAZARDS STAND BY PERSON
MECHANICAL HAZARDS SUITABLE ACCESS AND EGGRESS
THERMAL HAZARDS ESCAPE HARNESS REQUIRED
SLIP TRIP FALLS HAZARDS
ENTRAPMENT HAZARD
REQUIRED PRE-ENTRY HAZARD ELIMINATION MEASURES TAKEN YES N/A
ALL SLIP AND TRIP HAZARDS ELIMINATED
ATMOSPHERIC TESTING (OXYGEN, FLAMMABLE VAPORS/GASES AND TOXIC CONCENTRATIONS)
CONDUCTED AND DOCUMENTED ABOVE
ACCESS OPENING OBSTRUCTION HAZARDS ELIMINATED
SHARP EDGES REMOVED OR GUARDED
PHYSICAL BARRIERS OR BARRICADES INSTALLED
FORCED VENTILATION CAN ELIMINATE ATMOSPHERIC HAZARDS
CONTENTS OF THE SPACE REMOVED
CHEMICAL, UTILITY, AND OUTLET LINES ISOLATED
LOCKOUT/ TAG-OUT, AND TRYOUT PROCEDURES IMPLEMENTED
COMBUSTABLE %LEL
OXYGEN %
H2S – ppm
CO – ppm
OTHER HYDROCARON %
(Limits: combustible% of LEL, Oxygen – 19.5 to 23% by Vol, H2S 5ppm, CO – 25ppm, NH3 -25ppm, SO2 – 2ppm, Chlorine – 0.5ppm,
Benzene – 0.1ppm.) All Safe Testing Requirement
Every_______ Hrs.
Name:
Date & Time:
DO NOT ENTER IF PERMISSABLE ENTRY LEVELS ARE EXCEEDED
EXPECTED DURATION (CANNOT EXCEED ONE 8hr SHIFT): AUTHORIZED DURATION (NO MORE THAN ONE 8hr SHIFT):
PERSON IN CHARGE OF WORK: ENTRY SUPERVISOR:
AUTHORIZED ENTRANT (S): ATTENDANT (S):
AL THAIL GROUP OF COMPANIES
PERMIT ENTRY AUTHORIZATION
I CERTIFY THAT ALL EXISTING HAZARDS HAVE BEEN ELIMINATED AND ALL ABOVE CONDITIONS HAVE BEEN SATISFIED.
PRINT NAME AND TITLE: DATE & TIME:
DEPARTMENT AND PHONE: ENTRY SUPERVISOR OR QUALIFIED PERSON SIGNATURE:
EMERGENCY PROCEDURES: DO NOT ENTER THE SPACE UNDER ANY CIRCUMSTANCES. CALL 999. REMAIN AT WORK- SITE
UNTIL HELP ARRIVES.
ENTRY PROCEDURE CHECKLIST
COMPLETE THE FOLLOWING STEPS BEFORE, DURING, AND AFTER A CONFINED SPACE ENTRY
OBTAIN A PERMIT-CONFINED SPACE ENTRY FORM FROM PROGRAM COORDINATOR.
NOTIFY SUPERVISOR BEFORE THE CONFINED SPACE ENTRY
VERIFY CONFINED SPACE METER HAS BEEN CALIBRATED AND IS IN WORKING ORDER
COMPLETE THE TOP PORTION OF THE PERMIT-CONFINED SPACE ENTRY FORM
ENSURE ALL RESCUE EQUIPMENT (E.G. TRIPOD, BODY-BELT, LANYARD) IS IN PLACE PRIOR TO ENTRY
MONITOR THE CONFINED SPACE WITH THE MSA 4-GAS DETECTOR PRIOR TO ENTRY. THE ENTRANT AND ATTENDANT
SHOULD SIGN THE PERMIT AUTHORIZATION SECTION ON THE BOTTOM OF THE PERMIT TO ENSURE ALL ACTIONS
AND CONDITIONS NECESSARY FOR SAFE ENTRY HAVE BEEN PERFORMED.
EMPLOYEE ENTERING THE CONFINED SPACE SHOULD WEAR THE 4-GAS DETECTOR AFTER THE PRE-ATMOSPHERE
TEST. THE EMPLOYEE SHOULD ALSO HAVE A FULL BODY HARNESS AND LANYARD ATTACHED TO THE RESCUE
TRIPOD. EMPLOYEE SHALL HAVE A RADIO AND ANY OTHER NECESSARY PERSONAL PROTECTIVE EQUIPMENT.
EMPLOYEE CAN ENTER THE CONFINED ONCE STEP 7 IS COMPLETED. THE ENTRANT AND ATTENDANT SHOULD
COMPLETE THE HAZARDS OF CONFINED SPACES AND SPECIAL REQUIREMENTS SECTION OF THE PERMIT-CONFINED
SPACE ENTRY FORM ONCE THE EMPLOYEE IS WITHIN THE CONFINED SPACE. THE ENTRANT SHOULD ALSO GATHER
THE % OXYGEN, % EXPLOSIVE GASES, CARBON MONOXIDE, AND HYDROGEN SULFIDE READINGS AND
COMMUNICATE THEM TO THE ATTENDANT TO PLACE ON THE PERMIT FORM.
THE ATTENDANT SHOULD MAINTAIN CONSTANT COMMUNICATION WITH THE ENTRANT UNTIL THE ENTRANT HAS
EXITED THE CONFINED SPACE.
THE ATTENDANT SHOULD CONTACT SUPERVISOR ONCE THE ENTRANT HAS EXITED THE CONFINED SPACE.
THE PERMIT-CONFINED SPACE ENTRY FORM SHOULD BE GIVEN TO PROGRAM COORDINATOR, TO FILE IN THE
CONFINED SPACE RECORDS
LIFE SAVING RULES
PERMIT CANCELLATION/ HANDOVER
I HAVE VISITED AND INSPECTED THE WORKSITE. THE WORK DISCRIBED IN ABOVE SECTION
IS COMPLETE AND MATERIALS/ TOOLS/ EQUIPMENT HAVE BEEN REMOVED & AREA CLEANED
IS TO CONTINUE ON ANOTHER PERMIT
PERMIT HOLDER: DATE & TIME:
AL THAIL GROUP OF COMPANIES
(NAME & SIGNATURE)
AREA AUTHORITY: DATE & TIME:
(NAME & SIGNATURE)
DATE & TIME: PERMIT No: CONTINUED PTW No:
