WWTP Restricted Space Checklist
Building:
√ or X
Area:
Pre Entry Procedures
Is entry necessary?
Description of Work Required:
Names of Workers entering Restricted Space:
Name of Tending Worker:
Permit Time Request: Start:
am / pm
End:
am / pm
Is the Emergency response information posted on entrance door?
Supervisor specified requirements for restricted Space entry
Unobstructed access/egress
Recovery equipment required?
Task lighting required?
Tending worker required?
Additional Ventilation needs?
Note additional task specific PPE:
Other:
Building Management System readings
Are the make up air and exhaust fans operational?
Are the Methane, Hydrogen Sulfide and Oxygen readings normal?
Are all other systems operating in normal range?
Supervisor:
Date: