Confined Space Exercise #1 Submittal Page
Name:
Company:
Job Description:
Address1:
Address2:
City:
State:
Zipcode:
Email:
Telephone:
Confined Space Exercise#1
Confined Space Code:
Location:
Address:
City:
State:
Date:
Time Issued:
Expires At:
Cancelled At:
Cancelled By:
Describe Work:
Outside Contractors:
Other Acceptable Limit:
Other Acceptable Limit:
Blanking Performed?
Yes
No
Electrical Lock/Tag Out?
Yes
No
Mech. Lock Out?
Yes
No
Other Isolation:
Hotwork Permited?
Yes (requires completed hot work permit)
No
Corrosives:
Hot Equipment:
Flammable Materials:
Toxic Materials:
Spark Producing Operations:
Spilled Liquids:
Pressure Systems:
Other Identified Hazards:
Vessel Cleaned:
Yes
No
Time:
Inspected By (init):
Time:
Special Safety Precautions:
Ventilation Initiated?
Yes
No
Respirators Selected?
Air Purifying
Powered Air Purifying
Air Supplied
SCBA
Escape Only
None
GLOVES:
Chemical
Work
None
Boots:
Work
Chemical
Clothing:
Tyvek
Saranex
Work
Splash
OTHER-B
OTHER-C
LEVEL A
Hard Hat:
Yes
No
Harness:
Yes
No
Hoist:
Yes
No
Light:
Explosion Proof
Mechanic's
None
Polarity Checked:
Yes
No
Attendant Present:
Yes
No
Fire Extinguishers IN Place:
Yes
No
Emergency Response Notified/Posted:
Yes
No
Remarks:
Monitor Model:
Monitoring Method:
Continuous Readings
Periodic Sampling
Readings: (spaces may be left blank where appropriate)
O2:
LEL:
CO:
Other:
Loc:
Time:
Init:
O2:
LEL:
CO:
Other:
Loc:
Time:
Init:
O2:
LEL:
CO:
Other:
Loc:
Time:
Init:
O2:
LEL:
CO:
Other:
Loc:
Time:
Init:
O2:
LEL:
CO:
Other:
Loc:
Time:
Init:
O2:
LEL:
CO:
Other:
Loc:
Time:
Init:
O2:
LEL:
CO:
Other:
Loc:
Time:
Init:
Type of Entry:
Class C
Class B
Class A
Eligible Entrants:
Entrant:
Task:
Time In:
Out:
Entrant:
Task:
Time In:
Out:
Entrant:
Task:
Time In:
Out:
Entrant:
Task:
Time In:
Out:
Entrant:
Task:
Time In:
Out:
Eligible Attendants:
Attendant:
Task:
Time In:
Out:
Attendant:
Task:
Time In:
Out:
Attendant:
Task:
Time In:
Out:
Attendant:
Task:
Time In:
Out:
Attendant:
Task:
Time In:
Out:
Supervisor On Duty:
Supervisor:
Time In:
Time out:
Supervisor:
Time In:
Time out:
Communication Method(s):
Qualified Person's Name:
Emergency Communication Location:
Emergency Telephone Numbers: