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Morningside Campus Confined Space Permit


Job Location


Location & Description of Confined Space:   

Purpose of Entry:            Responsible Dept.:

Date (mm/dd/yyyy):      Time:      Expiration:




Phone Numbers


Morningside Security Phone Number: x 99

Project Supervisor:   

Environmental Health & Radiation Safety: x 48749

Other Emergency Numbers:




Responsible Individuals


Supervisor(s)/Project Manager(s)

Authorized Entrants

Authorized Attendants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



Special Requirements


Lockout/Tagout Complete

Yes   No

Escape Harness

Yes   No

Lines Broken—Capped or Blanked

Yes   No

Tripod

Yes   No

Purge—Flush or Inert

Yes   No

Life Lines

Yes   No

Ventilation—30 Min. in Advance

Yes   No

Fire Extinguishers

Yes   No

Secure Area—Signs, Barriers

Yes   No

Lighting (Explosion Proof)

Yes   No

Breathing Apparatus

Yes   No

Protective Clothing

Yes   No

Location of Emergency Phone

Yes   No

Respirator (Air-Purifying)

Yes   No



Atmospheric Testing

Limits

Time

Time

Time

Time

Time

Time

Time

Time

Time

Oxygen (%)

19.5 to 23.5

 

 

 

 

 

 

 

 

 

LEL (%)

> 10%

 

 

 

 

 

 

 

 

 

Carbon
Monoxide (CO)

25 ppm

 

 

 

 

 

 

 

 

 

Hydrogen
Sulfide (H2S)

10 ppm

 

 

 

 

 

 

 

 

 

VOC's

10 ppm

 

 

 

 

 

 

 

 

 

HCN

10 ppm

 

 

 

 

 

 

 

 

 

Ammonia

25 ppm

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 



Atmospheric Testing


Instruments Used:

Type:

Serial #:

 

 

 

 

 

 

 

 

 


Technician's Name: 




Authorization


Authorized Supervisor: 


Signature: _______________________________________________________________________________________


Date (mm/dd/yyyy): ________________________________________Time: ___________________________________