Confined Space Entry Permit
Permit Number: | CS-2050-001 |
Issued By: | [Your Name] |
Date: | September 15, 2050 |
Email Address: | [Your Email] |
Location of Confined Space: | Main Storage Tank Room, Building A |
Purpose of Entry: | |
Supervisor: | John Smith |
Entrants (List all personnel entering confined space):
Name | Job Title | Training | Rescue Training | Date of Birth | Contact Number |
Sarah Johnson | Maintenance Worker | Yes | Yes | 07/12/ 2030 | 222 555 7777 |
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Attendants (List all personnel stationed outside confined space):
Name | Job Title | Training | Rescue Training | Date of Birth | Contact Number |
Jenny Rodgers | Safety Officer | Yes | Yes | 06/08/ 2010 | 222 555 7777 |
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Emergency Contact Information:
Emergency Services: [911]
Nearest Hospital: [Unity Hospital]
Hospital Phone: [222 555 7777]
Hazard Assessment:
Describe all potential hazards within the confined space, including but not limited to:
Oxygen deficiency or enrichment Toxic gasses or vapors Flammable substances Engulfment hazards Physical hazards (e.g., sharp objects, moving parts) Atmospheric conditions
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Safety Precautions:
List all safety measures and precautions that must be taken before, during, and after entry, including:
Use of Personal Protective Equipment (PPE) Ventilation and air monitoring requirements Lockout/tagout procedures Lighting and communication equipment
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Equipment (List all equipment to be used during entry):
Equipment Description | Quantity | Inspection Date |
Gas Detector | 2 | 09/01/2050 |
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Communication Procedures:
Detail the communication protocols between entrants, attendants, and supervisors during the entry:
Radio frequencies Signal systems (e.g., hand signals, alarms) Check-in and check-out procedures
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Entry and Exit Procedures:
Provide specific instructions for entering and exiting the confined space:
Duration of Entry:
Start Time: [8:00 AM]
End Time: [12:00 PM]
Signature and Authorization:
I, [Your Name], authorize and confirm that all personnel involved in this confined space entry have been adequately trained and briefed on the safety procedures outlined in this permit.
Signature: [Signature]
Date: [09/15/2050]
Permit Expiry:
This permit is valid until [09/15/2050] at [12:00 PM]. Entry into the confined space is prohibited after this time without reevaluation.
Important Notes:
This permit is to be kept on-site and made available for inspection by authorized personnel.
In case of any changes or deviations from this permit, it must be immediately reviewed and updated by the supervisor.
Ensure compliance with all applicable safety regulations and guidelines.
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