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California Code of Regulation, Title 8, Section 5157. Permit -Required 0,)nfined Spaces, .. Page 1 of 3 <br />Subchapter 7. General Industry Safety Orders <br />Group 16. Control of Hazardous Substances <br />Article 108. Confined Spaces <br />New query <br />§5157. Permit -Required Confined Spaces, Appendix D - Confined Space Entry Permit. <br />Appendix D-1 <br />Confined Space Entry Permit <br />Date and Time Issued: <br />Job site/Space I.D.: <br />Equipment to be worked on: <br />Stand-by personnel: <br />Date and Time Expires: <br />Job Supervisor <br />Work to be performed: <br />1. Atmospheric Checks: Time <br />Oxygen % <br />Explosive $ L.F.L. <br />Toxic PPM <br />2. Tester's signature: <br />3. <br />Source isolation (No Entry): <br />N/A <br />Yes No <br />Pumps or lines blinded, <br />( ) <br />( ) ( ) <br />disconnected, or blocked <br />( ) <br />( ) ( ) <br />4. <br />Ventilation Modification: <br />N/A <br />Yes No <br />Mechanical <br />( ) <br />( ) ( ) <br />Natural Ventilation only <br />( ) <br />( ) ( ) <br />5. <br />Atmospheric check after <br />isolation and Ventilation: <br />Oxygen % <br />> <br />19.5 <br />Explosive % L.F.L <br />< <br />10 % <br />Toxic PPM <br />< <br />10 PPM H(2)S <br />Time <br />Testers signature: <br />6. <br />Communication procedures: <br />7. Rescue procedures: <br />8. Entry, standby, and back up persons: Yes No <br />Successfully completed required <br />training? <br />Is it current? ( ) ( ) <br />9. Equipment: N/A Yes No <br />Direct reading gas monitor - <br />tested ( ) ( ) ( ) <br />Safety harnesses and lifelines <br />for entry and standby persons ( ) ( ) ( ) <br />Hoisting equipment ( ) ( ) ( ) <br />Powered communications ( ) ( ) ( ) <br />SCBA's for entry and standby <br />persons ( ) ( ) ( ) <br />Protective Clothing ( ) ( ) ( ) <br />All electric equipment listed <br />Class I, Division I, Group D <br />and Non -sparking tools ( ) ( ) ( ) <br />http://www.dir.ca.gov/title8/5157d.html 6/4/99 <br />