Form CS-PERMIT-01: Confined Space Entry Permit

CONTROLLED DOCUMENT - Valid for ONE SHIFT ONLY

SECTION 1: PERMIT INFORMATION

Field	Information
Permit Number:	_________________
Date Issued:	_________________
Valid From:	________ (time)
Valid Until:	________ (time) Maximum 12 hours
Location/Site:	_________________________________________________
Space Description:	_________________________________________________
Space ID/Tag Number:	_________________

SECTION 2: WORK DESCRIPTION

Work to be performed:

Estimated duration: _____________ hours

Number of workers entering: _____________

SECTION 3: CONFINED SPACE VERIFICATION

This is a confined space if ALL THREE apply:

Fully or partially enclosed (not open to atmosphere)
Not designed for continuous human occupancy (not a regular workspace)
Restricted entry or exit (small openings, awkward access)

If all three boxes are checked → This is a CONFINED SPACE. Complete this permit.

SECTION 4: HAZARD IDENTIFICATION

Check ALL hazards present or possible:

[W016] Atmospheric Hazards:

Oxygen deficiency (less than 19.5%)
Oxygen enrichment (more than 23%)
Flammable gases or vapors
Toxic gases (H₂S, CO, etc.)
Asphyxiant gases (CO₂, nitrogen, argon)

[W017] Physical Hazards:

Engulfment (liquid, grain, sand, etc.)
Temperature extremes (hot or cold)
Noise exposure
Poor visibility
Slips, trips, falls
Moving equipment or parts

[W020] Configuration Hazards:

Inward-sloping walls
Narrow openings or passageways
Vertical entry (more than 4 feet deep)

[W012] Energy Hazards:

Electrical equipment or wiring
Mechanical equipment
Hydraulic or pneumatic systems
Process lines (liquid, gas, steam)
Gravity (materials that could fall)

Other Hazards:

Chemical residues or coatings
Biological hazards
Radiation
Other: _________________________________

SECTION 5: ISOLATION AND LOCKOUT

All energy sources MUST be isolated and locked out before entry.

Energy Source	Isolation Method	Lock/Tag #	Verified By	Initial
Example: Pump 123 motor	Breaker 4B locked open	Lock #456	J. Smith	JS

Process Isolation (valves, blanks, disconnects):

Line/Process	Isolation Point	Blank/Lock #	Verified By	Initial

Zero Energy Verified: [ ] YES - Attempted to start equipment, confirmed no movement

Verified By: _________________________ Initial: _______

SECTION 6: ATMOSPHERIC TESTING

Gas Monitor Make/Model: _______________________ Serial #: _____________

Last Calibration Date: _________________ Bump Test Done: [ ] YES

Test conducted by: _________________________ Time: _________

Acceptable Ranges: - Oxygen: 19.5% to 23% - LEL: Less than 10% - Carbon Monoxide: Less than 35 ppm - Hydrogen Sulfide: Less than 10 ppm

Initial Testing (before entry):

Location in Space	O₂ (%)	LEL (%)	CO (ppm)	H₂S (ppm)	Time	Initial
Top
Middle
Bottom

All readings acceptable? [ ] YES [ ] NO

If NO, describe actions taken: _____________________________________________

Continuous Monitoring (record every 15 minutes while occupied):

Time	O₂ (%)	LEL (%)	CO (ppm)	H₂S (ppm)	Tested By	Initial

SECTION 7: VENTILATION

Ventilation Required: [ ] YES [ ] NO

Type: [ ] Natural [ ] Forced Air (blower)

Blower Make/Model: _______________________ CFM Rating: _____________

Intake Location: _________________________________________________________ [P001] (No smoking/exhaust nearby)

Exhaust/Discharge: _______________________________________________________

Ventilation Duration Before Entry: _____________ minutes (minimum 15)

Continuous Ventilation During Entry: [ ] YES

Ventilation Verified Operating: [ ] YES By: _____________ Initial: _____

SECTION 8: REQUIRED EQUIPMENT AND PPE

Check ALL equipment and PPE in use for this entry:

Entry/Rescue Equipment:

Tripod/davit with rescue winch
Full-body harness (inspected, date: ______)
Retrieval line (attached to D-ring)
Ladder (secured, inspected)
Lighting (Class I Div 1 if needed)
Communication equipment (radio/phone)
Personal gas monitor (on entrant)
Fire extinguisher

Personal Protective Equipment:

[M014] Hard hat
[M002] Safety glasses or face shield
[M009] Work gloves
[M008] Safety boots
Coveralls or protective clothing
[M004] Respirator (type: ________________)
[M003] Hearing protection
Other: _________________________

All equipment inspected and serviceable: [ ] YES By: ____________ Initial: ____

SECTION 9: PERSONNEL ASSIGNMENTS

Entry Supervisor:

Name: _______________________________ Phone: _____________________

Signature: _______________________________ Time: _________

Authorized Entrants:

Name: _______________________________ Phone: _____________ Initial: _____
Name: _______________________________ Phone: _____________ Initial: _____
Name: _______________________________ Phone: _____________ Initial: _____
Name: _______________________________ Phone: _____________ Initial: _____

Attendant (stationed at entry):

Name: _______________________________ Phone: _____________________

Attendant Responsibilities Understood: [ ] YES Initial: _________

Maintain communication with entrants
Keep accurate count of entrants
Summon rescue if needed
[P003] NEVER enter space to rescue

SECTION 10: RESCUE ARRANGEMENTS

Rescue Method: [ ] Non-Entry (retrieval line) [ ] Entry Rescue Required

If Entry Rescue Required:

Rescue Team Notified: [ ] Fire Department [ ] Site Rescue Team [ ] Other: __________

Contact Name: _______________________________ Phone: _____________________

Notified By: _______________________________ Time: __________

Rescue Equipment Tested: [ ] YES By: _________________ Initial: _____

SECTION 11: [E009] EMERGENCY CONTACTS

Contact	Name	Phone Number
Emergency Services	911	911
Site Contact
4Core Supervisor
Entry Supervisor
Safety Officer

SECTION 12: ENTRY AUTHORIZATION

I certify that: - All hazards have been identified and controlled - All isolation and lockout procedures have been completed - Atmospheric testing shows acceptable conditions - All required equipment is in place and operational - All personnel are trained and understand their roles - Emergency response arrangements are in place

Entry Supervisor Signature: _________________________________ Date/Time: __________

ENTRY AUTHORIZED: [ ] YES

SECTION 13: ENTRY LOG

All entrants MUST sign in and out.

Name	Time IN	Initial	Time OUT	Initial

SECTION 14: CONDITION CHANGES / INCIDENTS

Record any changes to conditions, near-misses, or incidents:

Time	Description	Action Taken	By

SECTION 15: PERMIT CLOSE-OUT

Work Completed: [ ] YES [ ] NO

All workers accounted for: [ ] YES (_____ workers exited)

All tools and equipment removed: [ ] YES

Space restored to safe condition: [ ] YES

Lockouts removed per procedure: [ ] YES (LO-001)

Issues or concerns to report: [ ] NO [ ] YES (describe below)

Closed By: _________________________________ Time/Date: ______________

Entry Supervisor Signature: _______________________________________________

PERMIT CANCELLATION

If conditions change and entry must be stopped, cancel this permit:

Reason for Cancellation:

Cancelled By: ______________________________ Time/Date: ______________

RETENTION: Keep completed permits for minimum 2 years.

REMINDER: This permit is valid for ONE SHIFT ONLY. A new permit is required for each entry or each shift.

4Core Energy & Maintenance Ltd.