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CONFINED SPACE ENTRY PERMIT

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CONFINED SPACE ENTRY PERMIT CONFINED SPACE Location/Description/ID Number Date: ________________________________________ ________________________________________ ______ Purpose of ENTRY ________________________________________ ________________________________________ ________________________________________ ________________________________________ ____________ Time In: ______________ PERMIT Canceled Time: _____________________________________ Time Out: ____________ Reason PERMIT Canceled: ___________________________________ Supervisor: ________________________________________ ___________________________________ Rescue and Emergency Services- Hazards of CONFINED SPACE Yes No Special Requirements Yes No Oxygen deficiency Hot Work PERMIT Required Combustible gas/vapor Lockout/Tagout Combustible dust Lines broken, capped, or blanked

Entry Procedure Checklist: Complete the following steps before, during, and after a confined space entry: Step 1 Obtain a Permit-Confined Space Entry Form from Program Coordinator. Step 2 Notify Supervisor before the Confined Space Entry Step 3 Verify Confined Space Meter has been calibrated and is in working order Step 4

  Checklist, Entry, Space, Permit, Confined, Confined space entry permit

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