Section D
Confined Space Entry Permit
Chapter 2
Part A
Version: 0
Confined Space Entry Permit
Date:
Start Time:
End Time:
(Separate permit required for each job not to exceed 12 hrs.)
Area/Facility:
Confine Space Description/Purpose:
Hazards (Place X in box):
High H2S,
high/low oxygen,
NORM,
benzene,
SO2,
CO,
flammable gas,
MSDS),
poor light,
slippery surfaces,
low/high temperature,
electrical,
high noise level,
Other:
chemicals (see
Equipment (Place X in box):
Air Supplied Respirators,
air-driven or explosion-proof fan,
air eductor,
Tyvek clothing,
slicker
(rain) suit,
rubber gloves,
rubber boots,
safety harness and lifeline,
hearing protection,
hard hat,
goggles,
face shield,
hoist or block and tackle and mounting point directly over top entry,
gas monitor(s),
first aid equipment,
fire-fighting equipment,
low
voltage or explosion-proof lighting,
radios,
vacuum truck,
scaffolding,
GFCI,
danger signs,
barrier tape,
Other:
List all personnel involved in the confined space entry work (attach second page if necessary):
Print Name / Company / Title
Signature (use ink)
Entrant Y/N
Standby Person(s):



Is all piping/wiring disconnected, blinded or locked out? (See Lockout/Tagout Procedures)
Have all substances been flushed from the vessel and lines?
Has continuous forced draft ventilation been established?
Yes or No
Yes or No
Yes or No
Monitor continuously and record meter readings at least hourly below.
Time
Oxygen %
19.5-23.5
Flammability (%LEL)
<10
H2S (ppm)
<10
SO2 (ppm)
<2
Benzene (ppm)
NORM (µR/hr)
<1
<50
Other
Meter Model & Serial No:
Calibrators Name/Date:
Name of Meter Operator:
Reference Check Results:





Has breather and rescue equipment been checked and issued to each person involved in confined
space work? SCBA at entry for standby person?
Do all involved employees/contractors understand hazards, know responsibilities, have the proper
training, have protective equipment and understand a rescue plan (pre-job safety meeting)?
Have the Respiratory Protection and Lockout/Tagout procedures been reviewed and followed?
Is standby person trained in rescue, first aid, CPR, use of their assigned SCBA, their responsibilities
standby and the communication system with entrants?
Hot work Permit required? Attach copy.
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Approval Signatures:
Immediate Supervisor of Job/Task: Name (Print):
Signature:
Facility Person in Charge (PIC) or Consultant (Print):
Signature:
Company:
Date:
Company:
Date:
REV: August 2013
Fieldwood Energy LLC Safe Work Practices
Page D-2-A-1