Confined Space Entry Permit
Job/Task
Permit No.
Location of Confined Space
Date
Start Time
End Time
Supervisor
Workers Authorized for Entry
Name
Signature
Time In
Time Out
Attendants
Name
Signature
Atmosphere Testing
Test
Acceptable Range
Initial
Periodic
O
2
19.5% - 23.5%
Flammable Gas
< 10% LEL
CO
< 35 ppm
H
2
S
< 10 ppm
Other
Hazards Identified
Isolation & Lockout/Tagout
Electrical
Mechanical
Chemical
Hydraulic
Pneumatic
Other
Entry Permit Conditions
Ventilation Provided
Communications Established
Harness and Retrieval System
Respiratory Protection
Fire Extinguisher Available
Others
Emergency Procedures
Permit Authorization
Supervisor Name & Signature
Date/Time
Safety Officer Name & Signature
Date/Time
Permit Cancellation
Permit Cancelled By (Name & Signature)
Date/Time