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EHS

Appendix B

College of Saint Benedict Order of Saint Benedict Confined Space Entry Permit

Location & Description of Confined Space

Purpose of Entry

Scheduled Start (please indicate day, date & time)

Scheduled Finish (please indicate day, date & time)

Employee(s) in charge of entry

Entrants

Attendants

Pre-Entry Authorization

Types of Hazards (check those items which are applicable to your confined space permit)

Oxygen-deficient atmosphere

Oxygen-enriched atmosphere

Welding/cutting

Engulfment

Toxic atmosphere

Flammable atmosphere

Energized electrical equipment

Entrapment

Hazardous chemical

Types of Hazards (check those items which are applicable to your confined space permit)

Self-contained breathing apparatus

Air-line respirator

Fire-retardant clothing

Ventilation

Remarks

Protective gloves

Lifelines

Respirators

Lockout/Tagout

Fire Extinguishers

Barricade job area

Signs posted

Clearances secured

Lighting

Ground fault interrupter

Environmental Conditions

Tests to be Taken

Oxygen (% & date/time in a.m. or p.m.)

Lower Expoosive Limit (% & date/time in a.m. or p.m.)

Toxic Atmosphere

Instruments Used

Re-Testing

Oxygen (% & date/time in a.m. or p.m.)

Lower Explosive Limit (% & date/time in a.m. or p.m.)

Toxic Atmosphere

Instruments Used

Employee Conducting Safety Checks

Remark on overall condition of the confined space.

Entry Authorization

All actions and/or conditions for safe entry have been performed.

Person in Charge of Entry

Entry Authorization

Entry has been completed and all entrants have exited permit space.

Person in Charge of Entry

In Case of an Emergency Call 911 or CSB EMPLOYEES Call 5000, CONTRACTORS FOLLOW YOUR COMPANY PLAN.

FILE COMPLETED FORMS IN THE DEPARTMENT & SEND A COPY TO EHS. NOTE: KEEP POSTED ON-SITE WHILE WORK IS IN PROGRESS

Appendix B

College of Saint Benedict Order of Saint Benedict Confined Space Entry Permit

Environmental Conditions

In Case of an Emergency Call 911 or CSB EMPLOYEES Call 5000, CONTRACTORS FOLLOW YOUR COMPANY PLAN. FILE COMPLETED FORMS IN THE DEPARTMENT & SEND A COPY TO EHS. NOTE: KEEP POSTED ON-SITE WHILE WORK IS IN PROGRESS

In Case of an Emergency Call 911 or CSB EMPLOYEES Call 5000, CONTRACTORS FOLLOW YOUR COMPANY PLAN.

FILE COMPLETED FORMS IN THE DEPARTMENT & SEND A COPY TO EHS. NOTE: KEEP POSTED ON-SITE WHILE WORK IS IN PROGRESS