Alternate Entry Certification Form (See ES&H Manual Chapter 6160 Appendix T4 Alternate Entry Procedure for Instructions)

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

Use this form only if initial monitoring and evaluation indicates that the ONLY actual or potential hazard can be controlled through continuous ventilation.

Actual or potential atmospheric hazard can be controlled through continuous ventilation

Atmosphere in space will remain stable. Work in space will not degrade air quality.

If the PRSC hazards requires more than continuous ventilation to be eliminated or controlled then the space must be entered under Confined Space Entry Permit (See ES&H Manual Chapter 6160 Appendix T3 Entry Procedure for PRCS).

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 8-hours		Purpose of Entry:
If conditions change, exit the space, and call the Confined Space Coordinator.

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.” Keep emergency communication device (e.g. cellphone) at entry locations at all times.
Section 2 – HAZARD EVALUATION
Internal – Atmosphere:
Oxygen deficiency/enrichment Combustibles (LEL)	Carbon monoxide (CO) Hydrogen sulfide (H2S)
Other
Internal - Other e.g., electrical, mechanical, radiation, engulfment Acceptable Entry Conditions	Describe hazards and controls ( e.g.: LOTO, Communications, Ladders, Lighting)
External e.g. vehicle/foot traffic, engine combustion Acceptable Entry Conditions	Describe hazards and controls (Foot traffic – Caution barriers)
Introduced by the Work e.g. materials, chemicals, hot work Acceptable Entry Conditions	Describe hazards and controls: (e.g.: Hot Work – Hot Work Permit)

Section 3 - AUTHORIZING SIGNATURE

This certifies that the only hazard posed by the above referenced Permit-Required Confined Space is an actual or potentially hazardous atmosphere; and that continuous forced air ventilation is sufficient to maintain the space for safe entry. Signature below authorizes entry to Authorized Entrants listed, per OSHA 29 CFR1910.146(c)(5).

Entry Supervisor/

Authorized Entrant (Print & Sign):

Section 4 - ROLE ASSIGNMENTS
Entry Supervisor/Authorized Entrant(s):
Print Name:	Print Name:
Print Name:	Print Name:

Section 5 - INSTRUMENT VERIFICATION
Instrument Make/Serial No. (List all)	Calibration Expiration Date(s):	Bump Test Date:

Section 6 - 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			<10 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			<10 ppm
CO			<25 ppm
Others:

Section 7 – Certificate CLOSE-OUT
Close-Out Comments:
Qualified Entrant(Signature):	Date
Print	Time

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

Form Revision Summary

Revision 1.2 – 10/05/21 – Periodic Review; updated footer

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 – Per Technical Point-of-Contact: updated form format to reflect current template. Added “(Mandatory)” to Hazard Control Measures-Ventilation.

ISSUING AUTHORITY	FORM TECHNICAL POINT-OF-CONTACT	APPROVAL DATE	REVIEW DATE	REV.
ES&H Division	Jennifer Williams	04/21/15	10/05/24	1.2

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 10/5/2021.