Confined Space Entry Form Alcoa Fluor Alliance omepage进入受限空间的形式美铝氟联盟首页.docVIP

CONFINED SPACE ENTRY FORM Note!!! Ensure a project/facility-specific permit is not required before issuing this permit. Contractor: Plant Location: Sub-Tier Contractor: Contract/PO No.: The confined space entry form is comprised of four (4) separate parts: Evaluation Sections 1 through 5 Entry Permit Sections 6 through 14 Monitoring Requirements/Results Section 10 Entry Log Section 15 CONFINED SPACE HAZARD EVALUATION SECTION 1 PROJECT DESCRIPTION Purpose of Entry: Job Number: Reference Drawing: Other: SECTION 2 GENERAL INFORMATION Location (area, bldg., room, other): Space description (function, configuration, dimensions, type of space, above/below ground, access): Multiple access ports? Yes No SECTION 3 SPACE DESIGNATION 1. Is the space a confined space (all three criteria below have been met)? Yes No The space (check all boxes that apply) Is large enough and so configured that an employee can enter and perform assigned work. Has limited or restricted means of entry or exit. Is not designated for continuous employee occupancy. 2. Is this a permit-required confined space (any of the 4 conditions below have been met)? Yes No Does the space Contain, or have the potential to contain, a hazardous atmosphere? Contain a material that has the potential for engulfing an entrant? Have a configuration such that an entrant could become trapped or asphyxiated? Contain any other recognized serious safety or health hazards? 3. Space classification: Nonpermit Permit required N/A SECTION 4 HAZARD IDENTIFICATION (check those that apply) Yes No Oxygen deficiency (19.5%) Oxygen enrichment (23.5%) Flammable gases/vapors/dusts Inert atmosphere Welding/cutting fumes Toxic gases or vapors (specify) Refer to attached JSA or equal Yes No Mechanical hazards Electrical hazards Particulate Temperature extremes Pressure fluids/gases Introduction of hazardous mat