/ / 1st 2nd 3rd / / Permit date: Work shift: Expires: Time started: Permit space to be entered (name and location of space): Purpose of entry: Names of trained, authorized individuals Entry supervisor:  Entry attendant:  Authorized entrants:  Authorized entrants:  Emergency contact information Emergency responder: Phone number: Contact person: Time: Pre-entry requirements Requirements Yes No N/A Requirements Yes No N/A Lockout - tagout/de-energize Hot work permit Pipes(s) broken or capped or blanked Fall arrest harness/lifeline/tripod Purge or flush or drain Personal protective equipment Ventilation (natural or mechanical) Hardhat Secure area Gloves Safe lighting Safety glasses Non-sparking tools Respirator, type Communication method Other PPE: Contractor employees involved Other PPE: Space-monitoring results Test 1 Test 2 Test 3 Test 4 Monitor at least every Permissible entry Time: Time: Time: Time: Initial: Initial: Initial: Initial: four hours levels Percent oxygen 19.5% to 23.5% Combustible gas Less than 10% LEL Other toxic gas Other toxic gas Other toxic gas
Permit date: / / Work shift: 1st 2nd 3rd Expires: / / Time started: Permit space to be entered (name and location of space): Purpose of entry: Names of trained, authorized individuals  Entry supervisor:  Entry attendant:  Authorized entrants:  Authorized entrants: Emergency contact information Emergency responder: Phone number: Contact person: Time: Pre-entry requirements Requirements Yes No N/A Requirements Yes No N/A Lockout - tagout/de-energize Hot work permit Pipes(s) broken or capped or blanked Fall arrest harness/lifeline/tripod Purge or flush or drain Personal protective equipment Ventilation (natural or mechanical) Hardhat Secure area Gloves Safe lighting Safety glasses Non-sparking tools Respirator, type Communication method Other PPE: Contractor employees involved Other PPE: Space-monitoring results Test 1 Test 2 Test 3 Test 4 Monitor at least every four hours Permissible entry levels Time: Initial: Time: Initial: Time: Initial: Time: Initial: Percent oxygen 19.5% to 23.5% Combustible gas Less than 10% LEL Other toxic gas Other toxic gas Other toxic gas
entry-permit.docx