Form OP-150320 Attachment B "Confined Space Entry Permit" - Oklahoma

What Is Form OP-150320 Attachment B?

This is a legal form that was released by the Oklahoma Department of Corrections - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2019;
  • The latest edition provided by the Oklahoma Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OP-150320 Attachment B by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Corrections.

ADVERTISEMENT
ADVERTISEMENT

Download Form OP-150320 Attachment B "Confined Space Entry Permit" - Oklahoma

Download PDF

Fill PDF online

Rate (4.4 / 5) 23 votes
Attachment B
OP-150320
Page 1 of 2
CONFINED SPACE ENTRY PERMIT
Permit valid for eight hours unless otherwise noted on the form. This document will be posted at entry portal until
job/task is completed.
All requirements must be completed and reviewed prior to entry. Enter yes, or for items that do not apply, N/A; circle
items that apply. If any items are marked no, do not enter space - leave no space blank.
REVIEW ALL ITEMS AND CIRCLE THOSE
YES
NO
YES
NO
THAT APPLY OR WRITE IN SITE SPECIFIC
N/A
N/A
ITEMS
Line(s) broken, blanked, capped, blocked and
Lockout, tagout, tried to start equipment
bleed
Other work permits: Painting, welding, lift
Protective clothing
other__________________________________
______________________________
Mechanical ventilation:
SCBA, air line respirators, escape
Positive, negative, at source
bottle
Natural ventilation
Hot work permit
Secure area: flags, posts, barricades, other
Air purifying respirator and cartridges
__________________________________
Full body or chest harness with “D” ring
Communication equipment, voice
radio__________________________
Tripod with wench
Head, eye, hearing, hand, foot, face,
condition_______________________________
protection
Lifelines condition________________________
All electric, lights, tools, Class I Group I
Division D
Fire extinguishers
Flushing, clearing, purging
Continuously monitor. Record your findings at least every two hours. Watch for trends.
Tests to be taken
TLV, PEL, SDS, other____________
TEST 1
TEST 2
TEST 3
TEST 4
Oxygen
19.5-23.5% PEL
Combustible Gases
Below 10% of LFL
Carbon Monoxide
0-50 PPM PEL (0-25 PPM TLV)
Hydrogen Sulfide
O-10 PPM PEL
Other:
Instrument(s) used (model and calibration): _________________________________________________
Individual testing:
____________________________________________________________________________________
Name and Title
LFL =
Lower Flammable Limit
PPM = Parts Per Million
SDS = Safety Data Sheet
*PEL
= Permissible Exposure Limits as listed in OSHA 29CFR1910.1000
**TLV = Threshold Limit Values published by American Conference of Governmental Industrial Hygienists
Attachment B
OP-150320
Page 1 of 2
CONFINED SPACE ENTRY PERMIT
Permit valid for eight hours unless otherwise noted on the form. This document will be posted at entry portal until
job/task is completed.
All requirements must be completed and reviewed prior to entry. Enter yes, or for items that do not apply, N/A; circle
items that apply. If any items are marked no, do not enter space - leave no space blank.
REVIEW ALL ITEMS AND CIRCLE THOSE
YES
NO
YES
NO
THAT APPLY OR WRITE IN SITE SPECIFIC
N/A
N/A
ITEMS
Line(s) broken, blanked, capped, blocked and
Lockout, tagout, tried to start equipment
bleed
Other work permits: Painting, welding, lift
Protective clothing
other__________________________________
______________________________
Mechanical ventilation:
SCBA, air line respirators, escape
Positive, negative, at source
bottle
Natural ventilation
Hot work permit
Secure area: flags, posts, barricades, other
Air purifying respirator and cartridges
__________________________________
Full body or chest harness with “D” ring
Communication equipment, voice
radio__________________________
Tripod with wench
Head, eye, hearing, hand, foot, face,
condition_______________________________
protection
Lifelines condition________________________
All electric, lights, tools, Class I Group I
Division D
Fire extinguishers
Flushing, clearing, purging
Continuously monitor. Record your findings at least every two hours. Watch for trends.
Tests to be taken
TLV, PEL, SDS, other____________
TEST 1
TEST 2
TEST 3
TEST 4
Oxygen
19.5-23.5% PEL
Combustible Gases
Below 10% of LFL
Carbon Monoxide
0-50 PPM PEL (0-25 PPM TLV)
Hydrogen Sulfide
O-10 PPM PEL
Other:
Instrument(s) used (model and calibration): _________________________________________________
Individual testing:
____________________________________________________________________________________
Name and Title
LFL =
Lower Flammable Limit
PPM = Parts Per Million
SDS = Safety Data Sheet
*PEL
= Permissible Exposure Limits as listed in OSHA 29CFR1910.1000
**TLV = Threshold Limit Values published by American Conference of Governmental Industrial Hygienists
Attachment B
OP-150320
Page 2 of 2
CONFINED SPACE ENTRY PERMIT
Permit valid for eight hours unless otherwise noted on the permit. This document will be posted at entry
.
portal until job/task is completed
Location and identification of confined space:
Date:
Time:
Purpose of entry:
Duration:
Original supervisor name (Print):
Expires:
Current supervisor name:
AUTHORIZED ENTRANTS
Name
Title
AUTHORIZED ATTENDANTS
Name
Title
List all hazards of the confined space:
___________________________________________________________________________________
___________________________________________________________________________________
Rescue alarm/procedures and emergency services notification procedure (include method of contacting
trained rescue services without attendant leaving post).
___________________________________________________________________________________
We have reviewed the work authorized by this permit and the information contained here-in. Written
instructions and safety procedures have been received and are understood. Entry cannot be approved if
any risk(s) exist. This permit is not valid unless all items are completed. Permit prepared and approved
by: ____________________________________
Supervisor’s Signature
Any questions pertaining to confined space entry contact: _____________________________________
The supervisor (name) ______________________________ has safety canceled this permit and returned
the space to normal operation at (time and date) _____________________________________________
Remarks, suggestions, comments: __________________________________________________________
______________________________________________________________________________________
(R 9/19)
Page of 2