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W.O.# NW1-2337736 <br /> Confined Space Entry <br /> Tanknology,Inc. Checklist/Permit Safety Policy 100-06-A-Entry Permit Rev C <br /> Rev: C Field Form <br /> Date Effective: 9/08/2005 Page 1 of 2 <br /> Instructions: Tanknology requires that this form is completed for all jobs that involve ANY work in forecourt(tankfield). A copy must be <br /> submitted with the raw data file.Sections I and 11 must be completed for all sites. Sections III and IV to be completed as appropriate. <br /> SECTION I GENERAL INFORMATION <br /> Date: LC_ `, W.O.#: <br /> � •� <br /> Site name/#: I Technician(s): <br /> Scope of Work: i otential confined spaces: <br /> TP Sump I Fill Sump I Vault I Other: <br /> SECTION II NO CONFINED SPACE ENTRIES PERFORMED AT SITE <br /> A.L, WIork performed does not require removing sump lids <br /> B._Work only requires visual observation into sumps <br /> C._All work will be conducted without bodily entry using tools <br /> D._All work perfomred will be co ted from prone position with no risk of falling in sump. <br /> E._No confined spaces present. escr <br /> F._Work requires entry,proceed o sec n III Q <br /> Lead Technician Signature Date ! I <br /> ......................................................................................._................_................_........................................................._._.__._. _ <br /> SECTION III ALTERNATE E TRY/NON-PROS RECLASSIFICATION <br /> A.Alternate Entry(check to confirm that ALL uirements 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 /> 5. 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 /> B.Atmospheric Tests Monitoring Equipment Make/Model: Cal.Date: Bump tested(Y/N) <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) Reg STP„e(c. <br /> Depth to bottom of space FmOnchu <br /> TIME HOUR I MINUTE <br /> %of OXYGEN(02) 19.5-23.5% <br /> %of LEL flammable concentrations =0(none) <br /> OTHER(if applicable) Toxic(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 /> I. 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. Hotwork permit obtained — <br /> 7. Other — — <br /> SECTION III CONTINUED ON NEXT PAGE <br /> COMPANY CONFIDENTIAL ©Tanknology Inc.,2012.All Rights Reserved. <br /> rimed co ies of this document are uncontrolled. The current version is available in the Tankn010 On-Line Document Control S stem. <br />