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M• •• <br /> CSE <br /> Hazard Analysis Form <br /> Site Name <br /> Site Address <br />' CSE Name/Number <br /> i CSE Definition ❑ Vault ❑ Tank/Vessel <br /> ® ❑ Pit <br /> ❑ Other <br /> CSE Dimensions Sketch <br /> Length = <br /> Width = <br /> Depth <br /> ' Tars lActivity/Reasons for Entry Potential hazards within space Other CSE Hazards <br /> ❑ Well Gauging ❑ Oxygen Deficiency ❑ Greater than S' deep <br /> ❑ Bailing Product ❑ Combustible Vapors ❑ Difficult access/egress <br /> ❑ Pump Maintenance ❑ Toxic Vapors ❑ Energy/isolation' <br /> ❑ Well Sampling ❑ Engulfment ❑ Prone to flooding <br /> ❑ Product Recovery ❑ No Hazards ❑ Slippery surface <br /> ❑ ❑ Hot surfaces {i e , pipes} <br /> ^Check here a tOfTO must be performed <br /> IrI11d[r,.OfltiheC 3 3C! <br /> *"FOR USE BY AUTHORIZED CSE SUPERVISOR"* <br /> ' CSE Classification <br /> Class I Requirements <br /> ' Class II <br /> Class III <br /> ' Completed by Date <br /> Reviewed <br /> 6by Date <br /> ITE-SP <br /> S ECIE`IC CONFINED SPACES <br />