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CONFINED SPACE ENTRY RECORD <br /> The checklist must be displayed at the worksite in a visible manner for the duration of the work . <br /> Calibration of testing and monitoring equipment: Air testing and monitoring equipment shall be <br /> maintained and calibrated according to manufacturer's instructions . <br /> Location Date of Entry <br /> Time Issued Expiration Date <br /> Employee (s) assigned to enter <br /> Description of known hazards present in confined space <br /> c <br /> a) ° <br /> a m <br /> E <br /> u, > <br /> 0 0 <br /> A Atmospheric test — as often as required by :� Ch L t L L <br /> p <br /> program . o N co NT "' m <br /> 1 . Oxygen (19 . 5 % to 23%) <br /> 3 . Explosive Gases (less than 20% LEL) <br /> 3 . Carbon Monoxide (less than 35 ppm) <br /> 2 . Hydrogen Sulfide (be(ow 20 ppm) <br /> B Designated person performing testing (print) : <br /> CHECK ONE <br /> C Ventilate yes ❑ no El <br /> p Protective equipment/procedures for entry/rescue CHECK ONE <br /> 1 . Harness and lifeline on entrant yes ❑ no El <br /> 2 . Worker(s) wearing monitor yes ❑ no ❑ <br /> 3 . Worker wearing proper respiratory equipment yes ❑ no ❑ <br /> 4 . SCBA (5 min . or more) with worker yes ❑ no ❑ <br /> 5 . Spare harness and lifeline with observer yes ❑ no ❑ <br /> 6 . Spare SCBA ( 15 min . or more) with observer yes ❑ no ❑ <br /> 7 . Communication signals understood yes ❑ no ❑ <br /> 8 . Emergency procedures understood yes ❑ no ❑ <br /> Description of any additional hazards that may be expected to be generated by the entrance <br /> activities in the space and action taken to correct condition . <br /> Emergency Procedures <br />