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FEB 05 '99 14:41 FR CONTAINMENT SOLUT I ONS814 542 :5020 TO 9-15108958426 P.05/20 ENTRY TERMIT FOR PERMIT REQUIRED SPACES Location: Description of confined area: Permit number: Permit date: Description of work: Time issued: Time expired: Required if ENTRY CHECKLIST: to be completed by Name of Entry Supervisor(print) Name of authorized attendant(s) checked Entry Supervisor/Attendant or Entrant Confined space preparation ❑ All linen including vents to be disconnected and blanked off close to tank wheneve-possible,all tanks valves closed and locked. ❑ All electrical power switches locked off7 otherwtmn,electrical rwitcnem tagged Ott, ❑ MCCndnlCdl IS61atlon act:ieVed by disconnecting tinkates or refnoving di lve belts or chains,utherwlte,equipment with mechardCal parts blooked to wevent notation. ❑ Cleaning will be prrformr•d fmm outside)of ronfined Space ens rmir,as pobs!ttle arc tore entering,or pumped free of liquid material to one Inch nr lent;at which timr,thn spars may be entered to remove Solids. Confined space vented with blowers;all available ventilation operating. 77 Expected hazards 1?+lmhtg,wHld�rlg,braking,lir sOik•ptodurAng operatiuns planned. II yrs..has a hot work permit been obtained? ❑ Yes ❑No ❑ Toxic,comorive,or flammable matenDIS are present or used in work prochdurn_ ❑ rrAir..atmosphere may develop due to work pfooedures,desorption from walls,evaporation or residual chemicals,of nature of confined spaces ❑ Low oxygen concentration may be present or produced during entry. w. Employee OuaGfications• ,._...._. .�__ ,.__._ — _ ,,. _.— _ Name of authorized entrants Date SSN Trained ❑ An rnoployres requtrhE to tinter must have current(annual Confined Space Card. ❑ Standby employee has current Confined Space Card, ❑ Number of persons limited in absolute minimum. [� Standby stationed outside whore he/She can sec all activity in tank;no mb duties arr.tgned which eau from location, ❑ Standby trained in first 2id1CPR: othervdrr,pAredrral or fife fh:pertment alerted of dntry. ❑ Nearest telephoner posted with emergency numbers and inrtructionr Fire precautions ❑ Faro eMlnguisher immediately available. (Type A d C) ❑ Spark resistant tootS provided it flammable present. Hat Work Permit required ❑ Spark resistant tools prtmded it tlammablr,fon?cont Monitoring results Atmospheric testing o=% t EL°/d ppprn or ❑ Air monitor obtained,and verified in good wrinting order Before ri'mory ❑ A,r monitor IS wlthm current calibration. During enc ❑ operating conn nuoualygtt one worker In each entry or mmotpry Air monitor wom and orano poSltldned. ❑ Employee in9trueled to exit confined space immediately when alarm rounds, Personal protective equipment (Check Requirement) ❑ hkrrd hit ❑Respirator ❑Hard hat ❑ Faso Shield ❑Alr-Ione re5ptretor ❑ FaCe 5hleid ❑ ruing'" ❑SC.RA ❑ Goggles ® I fearing Protection ❑ ❑Hearing Protection ❑ Moor ❑other ❑ other Rescue and emergency ❑ 1-motgoncy SCSA equipment on Viand and ready fur immediate uric by ❑ Ali entrants wear harness and continually attached to lifeline, standby. (VnIeSS retrieval equipment woukt mereaSP overall rrFk of entry or would not contribute to the rescue of the entrant) (� b'tandby understands methods of amorgeney aloft,to other Health Unit 8 ❑ Pre-entry Safety mooting held employees briefed on rescue Frm Oapartment procedures. Authorization Si nature re wired before en Signature M entry supennSor Date Time Signature of attendant Date Time Signature of authuriked entrant Date lime 473•i9g ,