R1 Supplement 6709.12-97-1
Effective 09/05/97
6709.12,20 exhibit 04
Page 1 of 2
20 - EXHIBIT 04
CONFINED WORKSPACE INVENTORY & EVALUATION
Page 1 of 2
FOREST / DISTRICT:
DATE COMPLETED:
DESCRIPTION OF LOCATION:
DESCRIPTION OF WORKSPACE
NAME OF PERSON(S) COMPLETING INVENTORY AND TELEPHONE NO.
TYPE OF USE:
DEPTH OR LENGTH:
CUBIC FOOTAGE:
ENTRY METHOD:
(Ladder, built in rungs, etc.)
HISTORY - Any past problems?
- Frequency of past entry.
Number of manholes in the line.
POSSIBLE HAZARDS IN SPACE:
[ ] Mechanical
(Can moving parts or equipment
be locked out?)
[ ] Electrical (Can the source be
locked out?)
[ ] Physical
(wet, rusted steps
slippery, etc.)
[ ] Atmospheric (Gas, Oxygen, Flammables)
[ ] Are the hazards static or changing?
[ ] Surge flows (gas or liquids)
Can hazards be eliminated to permit safe entry?-If so, how ? (e.g., provide ventilation system to
provide oxygen and remove harmful gases).
[ ] Suffocation, Engulfment
Only trained employees, properly equipped will
be allowed entry--what means can be used to
deny entry to this space? (e.g., locking or
[ ] Other, please specify
etc.)
blockin
DESCRIPTION OF WORK THAT COULD BE DONE IN THE SPACE:
R1 Supplement 6709.12-97-1
Effective 09/05/97
6709.12,20 exhibit 04
Page 2 of 2
20 - EXHIBIT 04 -- Continued
Page 2 of 2
Instructions:
Complete this form for each confined workspace. Complete one form for each line of a sewer system where there are multiple manholes of a similar nature. List sewer
lift-stations individually. For example, if a sewage system consists of numerous manholes and a lift station, then you should submit two forms: one for all the manholes
and one for the lift station.
A confined workspace is a space that:
1.
2.
3.
Is large enough to allow entry.
Has limited or restricted means of entry or exit.
Is not designed for continuous occupancy.
Examples include: Cisterns, manholes, lift stations, deep trenches, tanks, sumps, vaults
pits, tunnels, shafts, silos, boiler tanks.
A permit-required confined space has one or more of the following:
1.
2.
3.
4.
Potential for hazardous atmosphere (i.e., low/high oxygen content or dangerous gas like hydrogen sulfide, methane, etc.).
Contains a material that has the potential for engulfing (i.e., dirt, grain, etc.).
Internal configuration could trap (i.e., crawl space that once entered is difficult to exit).
Contains any other recognized serious Safety or Health hazard.
Non-permit confined space: a confined space that does not contain or, with respect to atmospheric hazards, have the potential to contain any hazard capable of causing
death or serious harm.
Entry: Considered to have occurred as soon as any part of entrants body breaks the plane of an opening into the space.
All sewer openings are considered to be permitted confined spaces. See Appendix E of the Standard, 29 CFR 1910.146