12-1300-008I
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Baptist Health
South Florida
Confined Space Entry Permit
Date and Time Issued: Date and Time Expires:
Job site.: Job Supervisor:
Equipment to be worked on: Work to be performed:
Stand -by personnel:
1. Atmospheric Checks: Time
Oxygen %
Explosive % L.F.L.
Toxic PPM
2. Tester's signature:
3. Source isolation (No Entry): N/A Yes No
Pumps or lines blinded, ( ) ( ) ( )
disconnected, or blocked ( ) ( ) ( )
4. Ventilation Modification: N/A Yes No
Mechanical ( ) ( ) ( )
Natural Ventilation only ( ) ( ) ( )
5. Atmospheric check after
isolation and Ventilation:
Oxygen % > 19.5 %
Explosive % L.F.L < 10 %
Toxic PPM < 10 PPM H(2)S
Time
Testers signature:
6. Communication procedures:
7. Rescue procedures:
8. Entry, standby, and back up persons: Yes No
Successfully completed required
Training?
Is it current? ( ) ( )
9. Equipment: N/A Yes No
Direct reading gas monitor -
tested ( ) ( ) ( )
Safety harnesses and lifelines
for entry and standby persons ( ) { ) ( )
Hoisting equipment ( ) ( ) ( )
Powered communications ( ) ( ) ( )
SCBA's for entry and standby
persons ( ) ( ) ( )
Protective Clothing { ) { ) ( )
All electric equipment listed
Class I, Division I, Group D
and Non - sparking
tools
( )
( ) ( )
10. Periodic atmospheric
tests:
Oxygen %
Time
Oxygen %
Time
Oxygen %
Time
Oxygen %
Time
Explosive
Time
Explosive %
Time
Explosive %
Time
Explosive %
Time
Toxic %
Time
Toxic %
Time
Toxic %
Time
Toxic %
Time
We have reviewed the work authorized by
this permit
and the information
contained
here -in. Written instructions and safety
procedures
have been received
and are
understood. Entry cannot be approved if
any squares
are marked in the
"No" column.
This permit is not valid unless all appropriate
items are completed.
Permit Prepared By: (Supervisor)
0 N
Approved By: (Unit Supervisor)
Cn
12 m
Reviewed By (Cs Operations Personnel) .
(printed name) (signature)
This permit to be kept at job site. Return job site copy to Safety
Office following job completion.
Copies: White Original (Safety Office)
Yellow (Unit Supervisor)
Hard(Job site)
Appendix D - 2
ENTRY PERMIT
PERMIT VALID FOR 8 HOURS ONLY. ALL COPIES OF PERMIT WILL REMAIN AT
JOB SITE UNTIL JOB IS COMPLETED
DATE: - - SITE LOCATION and DESCRIPTION
PURPOSE OF ENTRY
SUPERVISORS) in charge of crews Type of Crew Phone #
COMMUNICATION PROCEDURES
RESCUE PROCEDURES (PHONE NUMBERS AT BOTTOM)
* BOLD DENOTES MINIMUM REQUIREMENTS TO BE COMPLETED AND REVIEWED
PRIOR TO ENTRY*
REQUIREMENTS COMPLETED DATE
Lock Out /De- energize /Try -out
Line(s) Broken- Capped - Blanked
Purge -Flush and Vent
Ventilation
Secure Area (Post and Flag)
Breathing Apparatus
Resuscitator - Inhalator
Standby Safety Personnel
Full Body Harness w / "D" ring
Emergency Escape Retrieval Equip
Lifelines
Fire Extinguishers
Lighting (Explosive Proof)
Protective Clothing
Respirator(s) (Air Purifying)
Burning and Welding Permit
Note: Items that do not apply enter N/A in the blank.
* *RECORD CONTINUOUS MONITORING RESULTS EVERY 2 HOURS
CONTINUOUS MONITORING ** Permissible
TEST(S) TO BE TAKEN Entry Level
PERCENT OF OXYGEN 19.5% to 23.5%
TIME
LOWER FLAMMABLE LIMIT Under 10%
CARBON MONOXIDE +35 PPM
Aromatic Hydrocarbon + 1 PPM * 5PPM
Hydrogen Cyanide (Skin) * 4PPM - -- -
Hydrogen Sulfide +10 PPM *15PPM
Sulfur Dioxide + 2 PPM * 5PPM
Ammonia *35PPM
* Short -term exposure limit: Employee can work in the area up to 15
minutes.
+ 8 hr. Time Weighted Avg.: Employee can work in area 8 hrs (longer
with appropriate respiratory protection).
REMARKS:
GAS TESTER NAME INSTRUMENT(S) MODEL SERIAL & /OR
& CHECK # USED & /OR TYPE UNIT #
SAFETY STANDBY PERSON IS REQUIRED FOR ALL CONFINED SPACE WORK
SAFETY STANDBY CHECK # CONFINED CONFINED
PERSON(S) SPACE CHECK # SPACE CHECK #
ENTRANT(S) ENTRANT(S)
SUPERVISOR AUTHORIZING - ALL CONDITIONS SATISFIED
DEPARTMENT /PHONE
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DATE 11 -19 -12
REVISED
JOB No.
1132086.0
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