Laserfiche WebLink
CSE"PERMIT <br /> I*his permit must be completed prior to entering any confined space and is ONLY VALID FOR THE DATE AND TIME <br /> t AIDICATED ON THIS FORM All procedural requirements contained in Flour Daniel GTI, Inc Health and Safety Policy and <br />' Procedure No 11 must be followed <br /> In the event a confined space emergency situation develops and rescue is required, notify the following appropriate emergency <br /> services <br /> Ambulance Fire Police <br /> Purpose of entry Location of confined space <br /> Date Authorized duration Expires on <br /> Atmospheric Hazards [ )Oxygen Deficiency [ ]Flammable [ )Toxic ( )Other [ )Other <br /> Physical Hazards [ ]Mechanical [ ]Electrical ( )Chemical [ ) Engulfment ( )Other <br /> PRE-ENTRY REQUIREMENTS <br /> Yes WA Yes WA <br /> Entry area is free of debris and objects ( ] [ ] Non sparking tools used <br /> ]] ( ] <br /> Warning barriers and signs are in place ( [ [ ] Low voltage(less than 25v)fighting used <br /> {] [ ] Atmosphenc monitoring conducted ( [ [ ! Electrical equipment rated for explosive atmospheres <br /> AR hazardous lines have been Isolated [ ] [ ] No compressed gas cylinders in the confined space <br /> ([ (} Hot work permit attached ( ] ( ] Host employer and/or contractors notified <br /> [[ [ ] All energy sources have been locked ouittagged out[] ( ] Entry and emergency procedures have been reviewed <br /> ([ [] The confined space has boon drained and flushed [ J [ ] All personnel have been trained(classroom/exercise) <br /> (l l 1 Forced air or exhaust ventilation Is provided [ ] [ ] All personnel have been informed of potenbat hazards <br /> Electrical equipment Is properly grounded ( ] [ ] Attendant stationed at entrance and property Inspected <br /> (J ( ] Ground fault c+rcurt interrupters(GFCI)provided [ ] [) Rescue equipment on location and readily accessible <br /> PROTECTIVE EQUIPMENT <br /> Yes No Yes No Yes No <br /> [] [ ] Hard Hat [ j [ ] Protective clothing [1 [ ! Communications Equipment <br /> EyeJFace Protect [j [ ] Heanng protection [] ( j Ventilation to Provide Fresh Air <br /> [] ( ] Boots [j [ ] Retrieval Devicefrnpod [] ( ] Respirator(type) <br /> (] [ ] Gloves [j [ ] Harness and Lifeline [] (J Other <br /> Atmosphere Acceptable Entry Time Time Time TimeTime Time Time Time Tom e Tlme T+me <br /> Test(s)to be Yes No Gondibons <br /> taken <br /> Allowable Umns Err rAir Monitoring Finclings Below <br />' 0xYQen 195% 220% <br /> Combustible Gas Below 10%LEL <br /> PIDlFID <br /> Carbon Monoxide 0-15 PPM <br /> H r en Sulfide 45 PPM <br /> H,d,ogen Cyanide 0-2 PPM <br />' Sulfur Olox+de 0-1 PPM <br /> Ammonia 0.10 PPM <br />' Other <br /> SUPERVISOR APPROVAL i certify that all necessary precautions have been taken to make this confined space safe for entering and conducting the work during the prescribed times)as welt <br /> as emergency response procedures <br /> Print Name Sign Name Date <br />' Envy Supervisor <br /> Permit Prepared by <br /> A:nosphere Tester <br /> Attendant <br /> ' EMRANTACKNOWLEDraEMENT f HAVE BEEN PROPERLY INSTRUCTED FOR SAFE ENTRY INTO THIS CONFINED SPACE AND UNDERSTAND MY DUTIES AND EMERGENCY PROCEDURES <br /> Print Entrant Name Sign Entrant Blame Employee or S 5 No Dat. Time <br /> An—1-1—shoald be pe Rortned to consider att potential air contaminants which Could be present and represent a hazard Rev 971+90 <br /> 0 r <br /> FLUOR DANIEL GTI <br />