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GETTLER - RYAN INC. ee65 Starr•nr.rr Suue G. cubr.n CA Witte CONFINED SPACE PRE-ENTRY CHECKLIST/REG LASSIFICATION—API 1646 Sertion 11 Atmospheric Tests(Pre- Time: r Oi W,� %LEL Toxicity(H;S.B ne-0 Isolation&Ventilation ,cid Q it (195%23.0/6): 00PPM Source Isolation Eledrical LOTO ❑YES ❑NO ❑NA I (Nn Envy) Pumps off&LOTO ❑YES ❑NO ❑NA Lines Disconnected ❑YES ❑NO ❑NA Valves shut and LOTO ❑YES ❑NO ❑NA Note:if any"No"is checked above or atmospheric tests are outside of acceptable range,fill out"Permit Required Confined Space EJWY Permit"section. If all"YES"or"NA"Continue on. Atmosphere I Mechanical Forced Air ❑YES ❑NO -L3-NA ventilation: Natural Ventilation Only ❑NO ❑NA Atmospheric Tests(Post. Timm t 02 � A %LEL Toxic ty Isolation&Ventilation -�Q 4 19.5°I�23 0°/° 0°6: HzS,Benzene C Pre- Surrounding Area Free of Hazards? D NO ❑NA Entry Roper notifications made? AnES ❑NO ❑NA Check Does your knowledge indicate the area will remain free of all J2'YES ❑NO ❑NA List atmospheric hazards? Are all entrants trained in confined space entry? 0,%s ❑NO ©NA Is the gas tester operator properly trained and authorized? YES 13 NO ❑NA Has the monitor been calibrated before use? YES ❑NO ❑NA Did you test the atmosphere in the space before en ES ❑NO ❑NA Did the atmosphere check as acc table? YES ❑NO ❑NA VH the atmosphere be continuousmonitored? EIVEI ❑NO ❑NA Life tine worn by ersonne!enterin ly g confined space? M YES ❑NO ❑NA Temperature of confined space acceptable range for entry Pi-YES ❑NO ❑NA <37.B'C or 100' ? Area barricaded with warning s' ns installed? ES ❑NO ❑NA Site specific rescue planalpched retain vrith ermi 7 S v _ ❑NO ❑NA j Trained rescue personnel and rescue erui pment on hand? MES ❑NO ❑5L I If confined space is under an inert atmosphere,is access E3YES ❑NO ZNA restricted to entry by contractorspecialized in inert entry. NOTE:IF ANY OF THE ABOVE ANSWERS ARE"NO",DO NOT ENTER Additnal harms.equipment site precaulmns.speaal requirements or instructons, • • welvilliql PuMose of Entry En Supervisor, Attendants 1. 2. Entrants: i. i 2. 3. 4. 3 4. Pre-Entry Checks: ❑L TO ❑Emergency Rescue Plan Secure Area blation PE ❑Lines IsotatedVocked es iratorsire Extinguisher OPurge ❑Hot Work Permit ❑Communication system 10 Lighling Minimum ReQuIremenIs To Be Cam leted&Reviewed Before Entry Continuous Test Allowable Initials Time- +A.� Time:^ Ti Tim . Time; r atmosphere limits —6 (�t •�V c Monitoring Oxygen 19.5%23-0% Vatue 'R Vaue: Vaue: • VA Vaue , Min Test Freq. LEL 0%(up to loxp1 Value Vahre Vaue: Value. Value ra, minutes wsuppled ar 1�� © C� reui alnruse HrS 5 PPM Value Value'. Vaue. Value- Vaue Other Value. Value: i Vatuc: Value: Iviue. Remarks: Gas Tester MakelModeVSerial Number. Instrument Calibration Date' Have all of the conditions above been satisfied? YES N ❑ Attendant signature: Entry Supervisor Signature: I ensure this permit has bein filled out ample y and in conjunction with all applicable OSHA i WorkSafe BU requirements to provide a safe workplace for all workers and myself. I wilt take action to eliminate hazardous conditions or acts identified on this iob site Permit Issuer(signature required): Company Name: Time lssued Date, Date&Time Work Completed Associated General Work Permit 1. Time exoires _'fW a hrs max. S( 2; I No. ADDITIONAL ❑Check it Gas Test is required ❑Check if continuous as Testing is required throughoul Job ❑Additional gas lest results form attached Gas Authorized Testing Gas Tester Date Time %LEL1LFL %02 H2S-PPM Other Results Other Results Instrument Initials t eP:m NIM 'V I n This form must be accompxared b%a salid General"Mk Pcmur Pape.