## 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**

**Recheck Test Results**

**Recheck Test Results**

|  |  |  |  |  |
| --- | --- | --- | --- | --- |

| Initials | Time of Entry | Time of Exit | Time of Entry | Time of Exit | Time of Entry | Time of Exit | Time of Entry | Time of Exit |
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