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<br /> ----- <br /> CITY OF ARDEN HILLS , ~I <br /> CONFINRD SPACE ENTRY PERMIT/CHECK LIST <br /> A. Date of Entry B. Location I <br /> C. Time Issued D. Expiration Date -I <br /> E. Employees Assigned to Enter <br /> F. Person in Charge Position <br /> G. Description of known hazards present in confined space I <br /> ReQ.Uired C011lPleted <br /> H. Atmospheric test before and during Yes No Yes No I <br /> I. Oxygen (19.5% to 23%) -- - - <br /> 2. Hydrogen Sulfide gas (below 20 ppm) -- - - I <br /> 3. Explosive gases (less than 10% LEL) -- - - <br /> I. Designated person performing testing I <br /> 1. Protective equipment for entry and rescue <br /> I. Harness and lifeline on person entering -- - - I <br /> and ties off or secured <br /> 2. Worker wearing monitor -- - - I <br /> 3. Worker wearing proper respiratory protection _ _ - - eI <br /> 4. SCBA (5 min. or more) with worker <br /> -- - - <br /> 5. Spare harness and lifeline with observer -- - - I <br /> 6. Spare SCBA (15 min. or more) with observer _ _ - - I <br /> 7. Ventilation equipment -- - - <br /> K. Description of any additional hazards that may be expected to be generated by the entrance I <br /> activities in the space and action taken to correct condition I <br /> L. Special work practices to be followed. I <br /> I. Communication signals reviewed <br /> 2. Emergency procedures understood <br /> M. Ventilate before and during I <br /> Personnel involved in this entry have received instructions on safety procedures and hazards of this job <br /> and the permit is complete I <br /> Signature of Person in Charge (on-site) -- <br /> Signatures of Person(s) assigned to enter I <br />