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California Code of Regulation- Title 8, Section 5157. Permit -Required "infined Spaces, .. Page 2 of 3 <br />We have reviewed the work authorized by this permit and the <br />information contained here -in. Written instructions and safety <br />procedures have been received and are understood. Entry cannot be <br />approved if any squares are marked in the "No" column. This permit is <br />not valid unless all appropriate items are completed. <br />Permit Prepared By: (Supervisor) <br />Approved By: (Unit Supervisor) <br />Reviewed By (Cs Operations Personnel) <br />(printed name) <br />(signature) <br />This permit to be kept at job site. Return job site copy to Safety <br />Office following job completion. <br />Copies: White Original (Safety Office) <br />Yellow (Unit Supervisor) <br />Hard(Job site) <br />Appendix D - 2 <br />ENTRY PERMIT <br />PERMIT VALID FOR 8 HOURS ONLY. ALL COPIES OF PERMIT WILL REMAIN AT <br />JOB SITE UNTIL JOB IS COMPLETED <br />DATE: - - SITE LOCATION and DESCRIPTION <br />PURPOSE OF ENTRY <br />SUPERVISOR(S) in charge of crews Type of Crew Phone <br />COMMUNICATION PROCEDURES <br />RESCUE PROCEDURES (PHONE NUMBERS AT BOTTOM) <br />* BOLD DENOTES MINIMUM REQUIREMENTS TO BE COMPLETED AND REVIEWED <br />PRIOR TO ENTRY* <br />REQUIREMENTS COMPLETED DATE TIME <br />Lock Out/De-energize/Try-out <br />Line(s) Broken -Capped -Blanked <br />Purge -Flush and Vent <br />Ventilation <br />Secure Area (Post and Flag) <br />Breathing Apparatus <br />Resuscitator - Inhalator <br />Standby Safety Personnel <br />Full Body Harness w/"D" ring <br />Emergency Escape Retrieval Equip <br />Lifelines <br />Fire Extinguishers <br />Lighting (Explosive Proof) <br />Protective Clothing <br />Respirator(s) (Air Purifying) <br />Burning and Welding Permit <br />Note: Items that do not apply enter N/A in the blank. <br />http://www.dir.ca.gov/title8/5157d.html 6/4/99 <br />10. Periodic atmospheric <br />tests: <br />Oxygen <br />% <br />Time <br />Oxygen <br />% <br />Time <br />Oxygen <br />% <br />Time <br />Oxygen <br />% <br />Time <br />Explosive <br />% <br />Time <br />Explosive <br />% <br />Time <br />Explosive <br />% <br />Time <br />Explosive <br />% <br />Time <br />Toxic <br />% <br />Time <br />Toxic <br />% <br />Time <br />Toxic <br />% <br />Time <br />Toxic <br />% <br />Time <br />We have reviewed the work authorized by this permit and the <br />information contained here -in. Written instructions and safety <br />procedures have been received and are understood. Entry cannot be <br />approved if any squares are marked in the "No" column. This permit is <br />not valid unless all appropriate items are completed. <br />Permit Prepared By: (Supervisor) <br />Approved By: (Unit Supervisor) <br />Reviewed By (Cs Operations Personnel) <br />(printed name) <br />(signature) <br />This permit to be kept at job site. Return job site copy to Safety <br />Office following job completion. <br />Copies: White Original (Safety Office) <br />Yellow (Unit Supervisor) <br />Hard(Job site) <br />Appendix D - 2 <br />ENTRY PERMIT <br />PERMIT VALID FOR 8 HOURS ONLY. ALL COPIES OF PERMIT WILL REMAIN AT <br />JOB SITE UNTIL JOB IS COMPLETED <br />DATE: - - SITE LOCATION and DESCRIPTION <br />PURPOSE OF ENTRY <br />SUPERVISOR(S) in charge of crews Type of Crew Phone <br />COMMUNICATION PROCEDURES <br />RESCUE PROCEDURES (PHONE NUMBERS AT BOTTOM) <br />* BOLD DENOTES MINIMUM REQUIREMENTS TO BE COMPLETED AND REVIEWED <br />PRIOR TO ENTRY* <br />REQUIREMENTS COMPLETED DATE TIME <br />Lock Out/De-energize/Try-out <br />Line(s) Broken -Capped -Blanked <br />Purge -Flush and Vent <br />Ventilation <br />Secure Area (Post and Flag) <br />Breathing Apparatus <br />Resuscitator - Inhalator <br />Standby Safety Personnel <br />Full Body Harness w/"D" ring <br />Emergency Escape Retrieval Equip <br />Lifelines <br />Fire Extinguishers <br />Lighting (Explosive Proof) <br />Protective Clothing <br />Respirator(s) (Air Purifying) <br />Burning and Welding Permit <br />Note: Items that do not apply enter N/A in the blank. <br />http://www.dir.ca.gov/title8/5157d.html 6/4/99 <br />