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SAFE WORK PERMIT FORM Job Name: Job Number: Company: Non-permit? 11 ❑ YES ❑ NO Permit#: Entry Supervisor or Person Requesting Permit: Location&Description of Confined Space: Purpose of Entry: Craft or Crafts doing work in confined space: Permit Begins:Date: Time: AM/PM Permit Expires: Date: Time: AM/PM METHOD OF COMMUNICATION Describe: Equipment Required For Entry Respirators Required For Entry Hard Hats YES NO ARE RESPIRATORS REQUIRED? YES NO Coveralls YES NO If YES What Type: Boots YES NO Have Employees Been Trained/Fit Tested/Med. Evaluation? YES NO Safety Glasses YES NO AIR-PURIFYING: Half-Mask: Full-Face: Safety Goggles YES NO Type of Filters: Face Shield YES NO AIR-SUPPLIED: and/or and/or Ear Protection YES NO Air Bottles Compressor Egress Bottles Encapsulated Suit YES NO SELF-CONTAINED BREATHING APPARATUS(SCBA): Gloves YES NO NOTE: Air-supplied respirators with egress bottles or SCBA respirators are required TYPE: for atmospheres that are Immediately Dangerous To Life or Health(IDLH) Lighting YES NO List any special: TYPE: Entry Conditions: Lockout Devices YES NO Training Required: Ventilation (mechanical) YES NO MSDS reviewed: Warning Lights YES NO Chemicals in the area: Fire Extinguisher YES NO Rescue Equipment required For Entry Ventilation/Blower YES NO Non-sparking Tools YES NO Rescue equipment YES NO SCBA YES NO Emergency Services: Other: YES NO Harness/Lifeline YES NO Other: YES NO Wristlets YES NO Special Instructions YES NO Tripod/Manlift YES NO Identify List: Winch YES NO First-Aid Kit YES NO Method of Communication Stretcher YES NO Other: Phone Number Acceptable Entry Conditions Oxygen: 19.5-23.5% F mmables/Combustibles Below 10% LEL Other: H dro en Sulfide 0-10 PPM TLV-TWA I Carbon Monoxide: 0— 10 PPM TLV-TINA I Other: Testing and Monitoring Checklist Make,Model&Serial#of testing Equipment: Date Equipment calibrated: Intermittent Testing Continuous Monitoring Test 1 Test 2 Test 3 Test 4 Test 5 Test 6 Test 7 Test 8 Test 9 Date: Time: Oxygen % % % % % % % r % LEL % % % % % % % % % CO PPM PPM PPM PPM PPM PPM PPM PPM PPM H2S PPM PPM PPM PPM PPM PPM PPM PPM PPM Toxic: Tester Initials: Hot Work Permit Is Hot Work Permit Required? YES NO If YES,Is it attached to this Permit? YES NO Signature of Person Authorizing Entry: Date: Time: Cancellation of Permit Signature Of Person Cancelling Permit: Date: Time: Reason Permit was Cancelled: