Attachment C "Odfw Confined Space Entry Permit" - Oregon

What Is Attachment C?

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

Form Details:

  • Released on May 15, 2012;
  • The latest edition provided by the Oregon Department of Fish and Wildlife;
  • 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 Attachment C by clicking the link below or browse more documents and templates provided by the Oregon Department of Fish and Wildlife.

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Download Attachment C "Odfw Confined Space Entry Permit" - Oregon

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Attachment C
ODFW Confined Space Entry Permit
Date & Time Issued
Date & Time Expires
Space I.D.
Location
Task
Potential Space Hazards
Electrical
Yes
No
N/A
Slippery Surfaces
Yes
No
N/A
Mechanical
Yes
No
N/A
Falls
Yes
No
N/A
Hazardous Configuration
Yes
No
N/A
Other
Engulfment Hazard
Yes
No
N/A
Space Preparation/Isolation Measures
All energy sources locked/tagged out
Yes
No
N/A
Pumps /lines blinded, blocked, disconnected
Yes
No
N/A
Space contents drained/flushed/neutralized
Yes
No
N/A
Vessel Cleaned/Purged
Yes
No
N/A
Mechanical Ventilation Provided
Yes
No
N/A
Natural Ventilation Utilized
Yes
No
N/A
Other
Atmospheric Testing Results
TIME:
TIME:
TIME:
TIME:
TIME:
TIME:
TIME:
Parameter
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
Oxygen
19.5 to 23.5
%
Flammables
Less than 10
% LEL
H2S
Less than 10
ppm
CO
Less than 25
ppm
Other
Testers
Initials
HR Policy 480_09
Page 1 of 2
May 15, 2012
Attachment C
ODFW Confined Space Entry Permit
Date & Time Issued
Date & Time Expires
Space I.D.
Location
Task
Potential Space Hazards
Electrical
Yes
No
N/A
Slippery Surfaces
Yes
No
N/A
Mechanical
Yes
No
N/A
Falls
Yes
No
N/A
Hazardous Configuration
Yes
No
N/A
Other
Engulfment Hazard
Yes
No
N/A
Space Preparation/Isolation Measures
All energy sources locked/tagged out
Yes
No
N/A
Pumps /lines blinded, blocked, disconnected
Yes
No
N/A
Space contents drained/flushed/neutralized
Yes
No
N/A
Vessel Cleaned/Purged
Yes
No
N/A
Mechanical Ventilation Provided
Yes
No
N/A
Natural Ventilation Utilized
Yes
No
N/A
Other
Atmospheric Testing Results
TIME:
TIME:
TIME:
TIME:
TIME:
TIME:
TIME:
Parameter
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
Oxygen
19.5 to 23.5
%
Flammables
Less than 10
% LEL
H2S
Less than 10
ppm
CO
Less than 25
ppm
Other
Testers
Initials
HR Policy 480_09
Page 1 of 2
May 15, 2012
Equipment Required (Specify as needed)
PPE
Respirators
Air Monitoring
Ventilation Equipment
Fall Protection
Rescue Equipment
Communication Equipment
Other
Emergency Notification
Location Address with Cross Street/Exit/Milepost as applicable:
Rescue Service:
Phone Number:
Person Responsible for making call:
Authorized Entrant(s)
Authorized Attendant(s)
Entry Supervisor (Please Print Name)
Entry Authorization by Entry Supervisor (Signature)
Date
Time
Maintain a copy of this permit in files at the site for two years.
HR Policy 480_09
Page 2 of 2
May 15, 2012
Page of 2