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Confined Space Permit Contracted personnel Only: Confined Space Entry Permit The fol lowing persons)trained in tonfnsed space procedures are assigned work in connection with a confined space eimy,in Space Description P n errnx Dare: a000rdance with this permit: Entrants(Pan!Nine) Atmndl-ts{PHnt Name) S P-15or(MA Hamel Fire W4WHot Work(port rwne) Lotation/Equlpment/Area: 5tart Time: ❑AAA 0PM Entry Purpose: End Time: DAM❑PM Joint Entry with Contactor Contractor's Affirmation on Tile❑Yes O No Hazard Assessment(Check✓all real or potential hazards) Atmosprienc I esvng Test mr.,x u.�.n in C EnguHment ❑Exposed Electricity ❑Mooing Machinery 05ips"Is ❑Hazardous Material ❑fleatstress ir �o �}, it Nm Ocer—grog Walls -'.Atmospheric Condition ❑other: xa xmretiemmebe traoor�s o�DEr—jFFn Air Man itoring(Perform at three 1 me rva I s) a.O-ysn[a2—% araan Din.ide(co2) u Carbon Monowd.{CO)____ppm Ammonia l NH3)wpm Name of Testty- Sigrsature: 2.0q tD21 'A Carbon Dio.ide(m21 v Canb—V6—id.(%O) Ammonia l N 113)wpm Personal Protective and Safety Equipment(Check J al that apply) 3.Owgen(O21 % Carbon Dioxide f0021 u Canboo M000wde Ammania(NN3)wpm C Retrieval linellwirt ❑Hard he El safety harness ❑Fire extinguisher Hazardous atmosphere is present ❑Yes O No If Yes,identify abnosp heric hazard: O Hearing protection ❑Ewoot protection ❑Ga-V0xygeRtToxdty Detectorts) Hazard Controls fGme to wp .dl CGFI In Wet EWIMnment ❑Ventilation equipment ❑Re&piMtDF/S(type): Outride Work area isolated with signs anWor harriers ❑Yes 0 No-NIA C Protective clothing Ispecifyl: ❑Me,—(speofy)- AII energy sources locked/tagged out ❑Yes 0 No-NIA All input I ines tapped/blinded ❑Yes 0 No-NIA —Communication equipment(sped=W ifVessel:drained,flushed,neutralized ❑Yes-No-NIA =Procedure for summoning help lspecify]: Ventilation Initiated 30 min-before entry ❑Yes-No-NIA — Fire extinguishers on hand ❑Yes G No-NIA _others(speciryl: ocher: ❑Yes 016.0 NIA E ntry Proced ure/Em p I oyee Train ing checked by(Manager]: 05afe Entry and Revue Training IDate: 1 _Attendant understands duties _Rescue plan is in place Type of En":Non-Permit ❑Entrant has lifeline, CEntrant understands exit requirement& AN hazard commis above are in plate_Yes 0 No 0 N/A ❑Attenda nt has communication to rescue Personnel Air Monitoring(Perform at three interva Isl C Pre-Entry Briefing:I/We have reviewed this pem rt and are aware of the hazards and precautions necessary for performing the 1.0hrm-L d{02) 9G Carbon 11-3e(CO21 % Carlson Monoxld.{CD)wpm Ammonia{NH31 wpm designated work in the confined space authormed bythis permit(signed by ofientrunts&efrendor t') 2.0�ffirn ferr1{02) % Carbon ll5.A.(CO21 % CSrhon Monoxids{CO)wpm Ammonia{NH3l wpm Name lslgnature) Name lsgnature) 3.01xfen l.vel{O2)_% Carbon Diomde(CO2} % Carlso n Monoaid.{CO)wpm Ammonia JNH31 wpm Ha2ardom atmosphere IS present ❑Yes 0 No 0 WA If yes,identify atmospheric hazard: All employeestrained ❑Yes 0 He 0 WA Atmospheric data available 0 Yes-No-WA Certification Air monitoring without entry ❑Yes 0 No O N/A continuous ventilation during entry 0 Yes_No_NIA I mniFythat al I existing and potential hazards have been evaluated,neecessary proactive measures have beentakenr and acceptable Continuous monitoring during entry ❑Yes 0 No 0 WA Space atmospheretested ❑Yes_No_NIA environmental conditions exist: Ventilation wlthoutentry ❑Yes 0 No 0 N/A No hazy rdous atmosphere ❑Yes C No-C NIA Retlassify Space from Penult to Hor,"Mit. Primed Name: signed: Date: Director of Ma inrenan[e Signature [Eletry Supervaan Na men : if al hazards cannot 6e eliminated,space is considered pe nnR required.STOP DO HOT ENTER;MOST 6E PERFORMED 6Y A LICENSED Emergency Phone Numbers 911 Other Rescue Team Police F`e CONTRACTOR. Permit Oa ncelle Vclosed at: by: Pefmn-Required 0 Yes Cl No cancel)ed by: {Entry Supeni-Ar Name1 Director of Maintenance Signature comments: SLd3mit Completed copies to the Maintenance Manager and Safety Departrreerrt. Revisor Date:0111112U23 Submit completed copies to the Maintenance Manager and Safety Department. Revision Date:0111112ID23