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PERMIT-REQUIRED CONFINED SPACE

Location of Confined Space: Space Number: Trade Shop: Purpose of Entry: Authorized Duration of Permit: Date: to Time: to Additional Permits (circle all that apply) : Burning Welding Brazing Cutting Open Flame

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PERMIT-REQUIRED CONFINED SPACE

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  1. Location of Confined Space: Space Number: Trade Shop: Purpose of Entry: Authorized Duration of Permit: Date: to Time: to Additional Permits (circle all that apply): Burning Welding Brazing Cutting Open Flame POSSIBLE HAZARDS PRESENT (circle all that apply): Oxygen deficiency Electrical shock Oxygen enrichment Engulfment Combustible dust Pressurized Systems Materials harmful to skin Flammable gases or vapors Toxic gases or vapors Mechanical hazards OTHER (please describe): HOW ARE HAZARDS BEING ELIMINATED BEFORE ENTRY (circle all that apply): Lockout/Tagout Disconnecting(blanking) Cleaning Forced Air Ventilation OTHER (please describe): EMERGENCY SERVICE: USC POLICE DEPARTMENT TELEPHONE: 7- 9111 AUTHORIZATIONS: Authorized Entry Employees: Authorized Attendant: Authorized Entry Supervisor: I certify that all required precautions have been taken and necessary equipment is provided for safe entry and work in the above listed confined space. Name(print): Signature: Date: PERMIT-REQUIRED CONFINED SPACE EHS-F-014 Page 1 Issue Date: 7/8/03 Destroy Previous Revisions Approved: _________

  2. I INITIAL GAS CHECKS - BEFORE VENTILATION IS APPLIED % Oxygen- Top: Middle: Bottom: Must be between 19.5%-23.5% %LEL - Top: Middle: Bottom: Must be less than 10% CO ppm- Top: Middle: Bottom: Must be less than 35 ppm H2S ppm- Top: Middle: Bottom: Must be less than 10 ppm PERIODIC ATMOSPHERIC TEST RESULTS : Is forced air ventilation being applied? (circle) YES NO Instrument reading must be: %Oxygen between 19.5% and 23.5% % LEL lower than 10 % CO ppm lower than 35 ppm H2S ppm lower than 10 ppm Initial Time %Oxygen %LEL CO ppm H2S ppm Comments EHS-F-014 Page 2 Issue Date: 7/8/03 Destroy Previous Revisions Approved: _________

  3. SIGNATURE FORM FOR ENTERING A CONFINED SPACE This form must be used any time a Confined Space Entry Permit is used. The observer/attendent must keep this form at the entrance of the Confined Space. Each person who enters and exists the Confined Space must sign and record the time on this form. If a person exits the Confined Space in a location other than where the observer is located, he must immediately report and sign this form. Name Time IN Time OUT Signature EHS-F-014 Page 3 Issue Date: 7/8/03 Destroy Previous Revisions Approved: _________

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