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Emergency Response Procedure—Include phone numbers and method of communication <br /> Does the Entry Require a Yes No Comments <br /> Confined Space Entry <br /> Permit <br /> Name of Person Signature <br /> Completing Checklist <br /> APPENDIX D-INSPECTION FORM- CONFINED CE FNTRV PERMIT TO WORK <br /> a Confined Space Entry Permit <br /> '�fJ0//lsll.O/,t Oi0/ / TiC... -:��d'/yl/c.:e- ,.p..,. .- si.•%�Iy .6i ' ,G'T ,G <br /> Date&Time Issued ����� V/0 Date&time Expires <br /> Entry Supervisor Name Entry Attendant Name <br /> Space I.D. Sp Service Station No. 'p Q <br /> Equipment Affected <br /> Name of All Entrants V1j <br /> Work Description G>� F Uri, "'Z1-Lr- <br /> Space Hazard Assessment Pre-entry brief has been <br /> has been reviewed by conducted with Entrants and ��� <br /> Attendants and Entrantsttendants. �+ <br /> E Supe ' or Signature Entry Supervisor Sig a ure <br /> Pre-Entry Atmospheric Checks <br /> Time(am-pm) <br /> Oxygen(19.5%-23.5%) ,q <br /> Explosive(<20/6 LEL) "'Q_' <br /> Toxic(PPM) <br /> Testers Signature ` h <br /> Testing Equipment Calibration Date . 1 <br /> Pre-entry Fluid System Yes No N/A If No or N/A,Why? <br /> Isolation <br /> Pumps/lines valve closed,or <br /> electrically disconnected <br /> Yolk Disconnected <br /> Ventilation Source Est Yes No N/A If No or N/A,Why? <br /> Mechanical Forced Air <br /> Communication Procedures P L <br /> Emergency services phone number(s) 1 <br /> Control Status: Controlled Revision Date: August 29,2004» <br /> PGPFq f`(1DIFC DAF 1 IAI!`(1NTRhl I Frl TNIC((1PV\/DI Ifl(lAll V DT THF TI�AF f1F PRINTIAI(_ <br />