Confined Space Entry Permit
Permit No.
Date
Time Issued
Time Expires
Location of Confined Space
Description of Work
Personnel
Name
Role
Signature
Entrant
Attendant
Supervisor
Atmospheric Testing
Test
Acceptable Range
Reading 1
Reading 2
Reading 3
Oxygen (%)
19.5 - 23.5
Combustible Gas (%LEL)
< 10
Toxic Gas (specify)
Tested By:
Hazard Assessment & Control Measures
Equipment Required
Ventilation
Communication
Lighting
Harness/Lifeline
Respirator
SCBA
Tripod
Other Precautions
Permit Authorized By (Name & Signature)
Date & Time