Form Number
Confined Space Entry Permit
Date:
EHS-00007-F1 R7
ERT Contact: Day 1 (518-956-1287 / 518-729-8504) or Day 2 (518-410-8685 / 518-956-0505)
Entry Time:
Time Completed:
This permit expires 8 hours after Date and Entry Time above.
Requestor Name/Phone #:
CNSE Work Sponsor/Phone #:
Contractor Name/Representative Phone #:
Entry Team Name(s)/Phone #(s):
Confined Space to be Entered:
Inventory Number (Use Numbers from EHS-00007 Appendix A):
Purpose for Entry:
IN CASE OF EMERGENCY (Call ext. 78600 or 518-437-8600)
Potential Hazards in Confined Space:
Protective Equipment Required:
Yes No
Oxygen Deficiency (<19.5%)
Flammable gases / vapors
(>10% LL, or > 23.5% oxygen)
Toxic Gases / Vapors (>TLV)
Mechanical Hazards
Electric Shock
Engulfment
Liquid solvents / acids
Other:
Belt, Harness, Lifeline
Breathing Apparatus
Tripod (Covers entire opening)
Gloves
Safety Glasses
Body Protection
Hearing Protection
Ventilator
Fire Extinguishers
Lighting (GFCI Required)
Additional Permits / Authorization Needed:
Authorized Entrants
(Print Name):
None
Hot Work
Signature:
Lockout /Tagout
Authorized Attendants
Type:
Type:
Type:
Type:
Other:
Signature:
(Print Name):
Do Not Write Below This Line – FOR CNSE ERT/EHS USE ONLY – Do Not Write Below This Line
Prior to Entry:
Communication:
Yes No
*Entrants & Attendants Confined Space Trained*
Space is Cleaned / Drained / Purged
Forced Ventilation Required
Periodic Air Monitoring Required; If yes, freq.
Space Barricaded
ERT/EHS Issued Confined Space Sign
Voice
Radio / Walkie-Talkie
Rope Pulls
Hand Signals
Cell Phone
Other:
min.
Air Sampling Results Table
Test
Allowable Limits (8 Hrs)
Time
ERT/EHS
Initial
Contractor
Initial
Time
Cont. 1
Time
Cont. 2
Time
Cont. 3
Oxygen (O2) Min. 19.5%-23.5%
Flammability
<10% LEL
Carbon Monoxide (CO) 25ppm
Hydrogen Sulfide (H2S) 10ppm
Other:
ERT/EHS: Confined Space is Safe for Entry: Yes
No
ERT/EHS: _________________________
Print
__________________________
Signature
Date: __________________
Supervisor: _________________________
Print
__________________________
Signature
Date: __________________
Permit and ERT Sign Must Be Posted During Work
*2 copies of Confined Space Training Certification MUST be submitted to Work Authorization Permit Meeting*
Printed copies are considered uncontrolled. Verify revision prior to use.
DCN1237
CNSE Confidential When Completed
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