Microsoft Word - Therma Confined Space Entry Permit.docx

Therma Confined Space Entry Permit

Job #	Job Name:				Date:
Job Location:				Description of work:
Name of Entry Supervisor:
Name of Entrants:				Name of Standby persons:



For items that do not apply, enter N/A
Requirements Completed	Yes	No	N/A	Requirements Completed	Yes	No	N/A
LOTO/De-energized/Tested				Appropriate PPE
Systems Purged/Flushed/Vented				Full Body Harness w/"D" Ring
Line(s) Broken/Capped/Blanked				Retrieval System in Place
Mechanical Ventilation				Workers Trained / Certs Current
Secure Area (Post & Flag)				Owner Notified of Entry
Lighting (Explosion Proof)				Affected Contractors Notified of Entry
100% GFCI Use				Respirators Required
Hot Work Permit				Communication System Tested
Extinguishers				Permit Posted at Entrance
Doors Removed or Blocked Open				Rescue Team Available
Signage Posted				Workers Informed of Hazards
Rescue Team Phone #:

PERMIT VALID FOR 8 HOURS ONLY.

I certify that all pre-entry conditions listed above on this permit have been met and the confined space is safe to enter.

Signature of Entry Supervisor	Date
PERMIT CANCELLED
Signature of Entry Supervisor	Date
Has this permit been cancelled due to any hazardous conditions? If YES, describe:	YES	NO

Air monitor: Model #: Unit #: Last Calibration:

Bump test: Flow test: Alarm at: O2: 19.5 LEL: 10 CO: 25 H2S: 10

Pre-entry air test by:

Air Monitoring Continuous Periodic (If Yes, what frequency?) _____

Pre-Entry Test Results

Oxygen	LEL	CO	H2S	Time of Test

Recheck Test Results