Confined Space Entry (CSE) Permit (See ES&H Manual Chapter 6160 Appendix T3 Entry Procedure for PRCS)

Call Newport News Fire Department (911) immediately in the event of injury to entrant(s) or indication of distress. Seconds may count!

SECTION 1 - INTRODUCTION
Post this permit at the entrance to the Permit-Required Confined Space (PRCS) for the duration of the entry
Space Designation	Nearest Permanent Building/Location					Type of Space
Start Date/ Time: Duration of entry is NOT to exceed one-shift			Purpose of Entry:
Call NNFD Station 6 at 757-881-5043, and Station 10 at 757-591-4915 to state the following: “This is not a request for an emergency response, just a notification that Jefferson Lab will be performing confined space entry.”
SECTION 2 - HAZARD CONTROL MEASURES ( Ö if “Yes” and describe as applicable)
Hazardous Atmosphere Ventilation (Mandatory) Electrical (Describe Lock Tag Try or other method below) Moving Machinery (Describe securing technique such as LTT) Respiratory Protection (Describe type and reason below) Purging/flushing technique (Describe LTT below) Entrance barrier, warning signs (Describe type below) Standing water removal (Describe below) Falling object protection (Describe below) Chemicals used inside the confined space (Describe below) Other Special Work Practices (Describe below)					Hot Work Permit Contact Confined Space Coordinator Engulfment Mitigation (including liquids & gases) Lines Capped/Blanked Valves closed LTT Applied Yes or No
					Other :
					PPE required: Protective eye wear (Mandatory) Hard hat Protective clothing / gloves Other:
Description (Use additional pages as necessary):
SECTION 3 - EQUIPMENT(Ö if “Yes” and describe as applicable)
Required: Emergency Communications (Mandatory) Retrieval Gear (if Öed then you need): Lifeline and body harness (If not Öed then describe why below) Retrieval Hoist (required for entry into below-grade spaces)				Other - Based on Actual Conditions:
				Lighting (vapor-tight) GFCI for electrical equipment Portable generator			Pump Batteries Other
Describe Other Equipment (Use additional pages as necessary):
SECTION 4 - ROLE ASSIGNMENTS
Authorized Entrant(s):		Attendant(s) Required:
Print Name:		Print Name:
Print Name:		Print Name:
SECTION 5 - AUTHORIZING SIGNATURE
Entry Supervisor (Print & Sign):

SECTION 6 - INSTRUMENT VERIFICATION
Instrument Make/Serial No. (List all)	Calibration Expiration Date(s):	Bump Test Date/Time:

SECTION 7 - ATMOSPHERIC TESTING
Initials of Person Performing Test
Tests Required			Acceptable Entry Conditions	Time	Time	Time	Time	Time
				Results	Results	Results	Results	Results
Oxygen (O2)	Always		19.5-23.5%
Combustibles	Always		<10% LEL
Toxics:	Yes	No
H2S			< 5 ppm
CO			<25 ppm
Others:
Hourly Test Results
Initials of Person Performing Test
Tests Required Pre-entry monitoring required if the space is left unattended (e.g. lunch, etc.)			Acceptable Entry Conditions	Time	Time	Time	Time	Time
				Results	Results	Results	Results	Results
Oxygen (O2)	Always		19.5-23.5%
Combustibles	Always		<10% LEL
Toxics:	Yes	No
H2S			< 5 ppm
CO			<25 ppm
Others:

SECTION 9 – CONFINED SPACE ENTRY LOG
Person Entering Space (Entrant’s Name)	Time IN	Time OUT

SECTION 8 – PERMIT CLOSE-OUT
Close-Out Comments:
Entry Supervisor (Signature):	Date
Print	Time

Submit the closed permit to Confined Space Coordinator when entry is complete.

Form Revision Summary

Revision 1.3 – 09/11/18 – Change in exposure limit for hydrogen sulfide, correction to the duration of entry permit, and additional information for hazard controls

Revision 1.2 – 10/14/16 – Updated to reflect current laboratory operations

Revision 1.1 – 04/21/15 – Periodic Review; updated LOTO comments and mandatory attendant

Revision 1.0 – 06/19/12 – Periodic Review; updated to reflect current laboratory operations

Revision 0.1 – 09/23/10 – Updated form format to reflect current template; added “Mandatory” to the Hazardous Atmosphere Ventilation hazard control measure per TPOC

ISSUING AUTHORITY	FORM TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW DATE	REV.
ESH&Q Division	Jennifer Williams	09/11/18	09/11/21	1.3

This document is controlled as an on line file. It may be printed but the print copy is not a controlled document. It is the user’s responsibility to ensure that the document is the same revision as the current on line file. This copy was printed on 10/10/2018.