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W.O.# NW1-2328941 <br /> F c' Tanknology,Inc. Confined Space Entry Safety Policy 100-06-A-Entry Permit Rev <br /> Checklist/Permit <br /> Rev: C Field Form <br /> Date Effective: 9/0$[2005 Page 1 of 2 <br /> Instructions: Tanknology requires that this form is completed for all jobs that invoke ANY Work in forecourt(tankfield). A copy must be <br /> submitted with the raw data file.Sections]-and]I.must becomnleted for all sites. Sections III and IV to be completed as appropriate. <br /> SECTION I GENERAL INFORMATION <br /> Date: Q ' W.O.#_ <br /> Site name/#: S _ Technician(s); <br /> Scope ofWoList otential confined spaces: <br /> TP Sum I Fiil Sum 1 Vault I Other: <br /> SECTION II NO CONFINED SPACE ENTRIES PERFORMED AT SITE <br /> A, Work performed does not require removing sump lids <br /> B.f Work only requires visual observation Into Sumps <br /> C. ,/All work will be conducted without bodily entry using tools <br /> D.All work performed will be completed from prone position with no risk of falling in sump. <br /> E._No confined space present. Describe: <br /> __ <br /> F._ ,Work requtrespritry`;proceed to section III <br /> Lead Technician Signa Date <br /> f <br /> SECTION III ALTERNATE ENTRY/NON-PRCS RECLASSIFICATION <br /> A.A[urnate Entry(check to confirm that ALL requitement%are satisfied) <br /> 1.. All employees trained <br /> 2. All other hazards eliminated(list) <br /> 3._Ventilation and monitoring prior to entry demonstrate ability to maintain safe atmosphere <br /> 4. Continuous ventilation and monitoring during entry <br /> S. No customer or other requirements to classify space as permit-required <br /> 6. if work performed can change atmosphere Alternate Entry will be cancelled <br /> 13.Atmospheric Tests Monitoring Equipment Make/Model: Cal.Date: Bump tested(YW) <br /> Test must be taken in the following order: Acceptable <br /> Test to be Taken Limit Test Results <br /> Name of Space(may list multiple spaces) R."STP"d, <br /> Depth to bottom of sp'te ce Peeum-h,, <br /> TIME HOUR;MINUTE <br /> of OXYGEN(0,) 19.5-23.5% <br /> 9u of LEL flammable concentrations. 0(none) <br /> OTHER(i f appli cable) Toxi c(or N/A) <br /> Initials of Lead Technician Initials <br /> C. Safety Requirements(Applies to all C.S.Entries) Yes No N/A Comments <br /> L Area barricaded _ <br /> 2. Lockout/Tagout completed and verified _ <br /> 3. Sources of ignition controlled <br /> 4. Pressure relieved from piping <br /> 5. Cleaning(flushing-washing)done <br /> 6. Botwork permit obtained <br /> 7. Other <br /> SECTION III CONTINUED ON NEXT PAGE <br /> COMPANY CONFIDENTIAL (D Tanknology Inc.,2012.All Rights Reserved. <br /> rimed copies ofthis document are uncontrolled. The current version is available in the Tanknology On-Line Document Control System. <br />