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• STATION SYSTEMS,INC. <br /> d"ED SPACE ENTRY!PERMIT <br /> COMPANY <br /> CONFINED SPACE ENTERED � ' 15 1P Somp <br /> LOCATION ZS -7-?s S - DATE 1 I / Z <br /> DESCRIPTION OF WORK TO BE PERFORMED �0 S Lr�E l�- �2�A�✓L( <br /> PERMIT EXPIRATIONI DATE-TIME / / D <br /> NATURE OF HAZARDS IN CONFINED SPACE:(check) EQUIPMENT REQUIRED FOR ENTRY AND WORK;(check) <br /> ✓ Oxygen deficiency(less than 19.5%at sea level) Respirator Lighting(explosion proof) <br /> Flamrroble gases or vapors(greater than 10%of _ Lifeline and safety harness Fire extinguisher <br /> the lower flammable limit,or greater then 23.5%oxygen at sea level) _ Protective clothing Emergency escape retrieval <br /> ✓Toxic gases or vapors(greater than the permissible exposure limit) _ Hearing Protection equipment <br /> Mechanical hazards ✓Standard work equipment(hard hat,boots,eye protection) <br /> X Electrical shock Electrical equipment and tools: <br /> f Materials harmful to the skin ✓Low voltage <br /> 7 Engulfment Ground fault current interrupters <br /> 7 Configuration hazard _ Approval for hazardous locations <br /> _ Other Respiratory protection(specify) <br /> Other Communication aid(specify) <br /> Rescue equipment(specify) <br /> PREPARATION: (check) AUT ORIZED ENTRANTS: <br /> /Notify afrected departments of service interruption <br /> Isolate-blanked or double valve,with lock and lag <br /> Zero energy state(lock-out all energy sources) <br /> Cleaned,drained,washed and purged <br /> -7Ventilation to provide fresh air AUTHORIZED ATTENDANTS: <br /> y/Emergency response team available U���'—[ <br /> Eniployees informed of specific confined space hazards <br /> /Secure area(post,sign and flag) <br /> �//Procedures reviewed with each employee STAND BY SAFETY PEALS N�EL`c� <br /> f: Amnospheric test in compliance S <br /> _ AtLach hot work permit <br /> _ Other <br /> Other <br /> TEST Allowable limits Check if Result Result Result Result Result Result <br /> Time Required 1041�vl _AM _AM _AM —AM _AM <br /> —PM —PM _PM _PM —PM _PM <br /> Oxygen-mittinnun 1915% � }�.� <br /> Oxygen-npaximunt 23.5% �V r <br /> Flammability 10%LEL I Regular sttrm <br /> Flammability 10%LEL/Pitts duly — <br /> Flanunability 10% LFI /Premium sums _ <br /> Flammability 10%IFI /Diesel <br /> SO2 2 PPM <br /> Heat OF/OC — <br /> Other — <br /> Name of employee conducting atmospheric monitoring: <br /> Imttwnent(s)used: <br /> AUTHORIZATION, <br /> I certify that all required precautions have been taken and necessary equipment Name (Print) <br /> is provided for safe entry and work in this confined space <br /> Time: L` Date: j 2 -0,4 Sigtwt <br /> J <br /> (Enclosure 1) <br /> Revised 1/16/01 i <br />