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Appendix F: Permit Form for Confined Space Entry SECTION IV – Atmospheric Testing Testing Equipment Used Model I.D. Number I certify equipment is in calibration. _______________________________________________ Phone:__________________________________ __ (Signature of tester) Initial Check Pre-entry Periodic re-check (Reading at least every 30 minutes.) Atmospheric Testing Need ? Time:______ Results/Initials Need ? Time:______ Results/Initials Need ? Time:______ Results/Initials Time:______ Results/Initials Time:______ Results/Initials Time:______ Results/Initials Oxygen (19.5%- 23.5%) Yes Yes Yes Combustibles (<10% LEL) Yes Yes Yes Carbon Monoxide (< 35 ppm) Yes Yes Yes Hydrogen Sulfide (< 10 ppm) Yes Yes Yes Other (list) Other (list) SECTION V – Emergency Action In the event of a confined space emergency call 911 if using a campus phone or 684-2444 if using a cellular. Provide detailed information to the emergency operator letting them know it is a confined space emergency, the specifics of the emergency, and location of the emer gency. Note any additional requirements/ information: _________________________________________________________________________________________________________________________ SECTION VI – Permit Cancellation Permit Cancelled by:______________________________________________________ Date_________________________Time:______________ Permit was canceled because (check one) __ Work has been complete __The permit has expired __Emergency (specify)_ _______________
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