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. 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 one shift

 

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 (check all that apply):

 

 Oxygen deficiency/enrichment

 Combustibles (LEL)

 

Check if these conditions are true:

 Actual or potential atmospheric hazard can be controlled through continuous ventilation

 Work in space will not degrade air quality.

 Carbon monoxide (CO)

 Hydrogen sulfide (H2S)         Other?

 

 

 Atmosphere in space will remain stable.

 

 Acceptable Entry Conditions   

Internal - Other

e.g., electrical, mechanical, radiation, engulfment

 Acceptable Entry Conditions

Describe hazards and controls ( e.g.: LTT, 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

Authorized Entrant(s):

Print Name:

Print Name:

Print Name:

Print Name:

 

Attendant required?    YES         NO                 If yes, Print attendant(s) 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

 

 

< 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 7 – Certificate CLOSE-OUT

Close-Out Comments:

 

Entry Supervisor (Signature):

 

Date

 

Print

 

Time

 

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

Form Revision Summary

Revision 1.2 – 10/03/18 – Periodic Review; minor revisions 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 – 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.

 

 

ESH&Q Division

Jennifer Williams

10/03/18

10/03/21

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 10/3/2018.