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r Ah Ah <br />C FINED SPACE ENTRY PERNTT <br />General Location of Work: Get -N -Go Market, 574 West Grant Road, Tracy, California <br />Exact Name of Confined Space: UST, inspection & possible repair <br />Possible Atmospheric Hazards, in any: Oxygen deficiency, organic vapors (gasoline/diesel) <br />Possible Safety & Related Hazards: Slips, trips, falls, traffic, flammable atmosphere <br />Hazardous Materials to be used/generated YES or NO (If yes, list by chemical name): <br />REQUIRED CONTROLS <br />Done <br />N/A <br />Explanation <br />Isolations & Lockouts, Try -Out <br />Ventilation Natural or Mechanical <br />Personal Protective Equipment <br />Body Harness & Line, Hoist <br />Emergency Lights <br />Communications (Verbal, Radio, Tug <br />Signals, Air Horn, etc. <br />Emergency Procedures Review <br />Grounding & Bonding <br />Welding Permit <br />Fire Extinguisher <br />Area Security Post & Fla <br />Rescue Service Contacted <br />AIR TESTING <br />(Continuous air monitoring required at all <br />times unless otherwise noted. <br />Results <br />Time <br />By <br />Results <br />Time <br />By <br />Results <br />Time <br />By <br />(Acceptable Limits in Parenthesis) <br />Oxygen 19.5 - 23.5%) <br />Lower Flammable Limit <10%) <br />Carbon Monoxide <35 m <br />Hydrogen Sulfide <I0 m <br />Other/Comments <br />Instrument Used: GasTech Model: GT201 Serial No.: 9827127 <br />TtAL PERMIT ISSUED: Time/Date to Time/Date (12 hours max. <br />11N <br />Certified Confined S ace Monitor Initial Review: <br />Supervisor(s) Acknowledgement: I understand that I am responsible for ensuring that attendants and entrants are <br />properly trained (includes review of this permit) and that all permit requirements and related confined space entry <br />procedures are met for this entire operation. <br />Permit Renewals (time/date/person) <br />PERMIT WILL REMAIN AT SITE UNTIL JOB IS COMPLETED <br />