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Appendix B

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









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









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















Environmental Conditions

Tests to be Taken




Re-Testing






Entry Authorization

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

Entry Authorization

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

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