Permit Request • CampusOptics

Requester Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Name* Required

Additional Location Details

Part A. Hazard Assessment

CONFINED SPACE NO. AND DESCRIPTION:* Required

LOCATION OF CONFINED SPACE:* Required

DESCRIPTION OF WORK PERFORMED:* Required

ENTRY SUPERVISOR:* Required

ATTENDANT:* Required

ENTRANT(S):* Required

MATERIALS OR CHEMICALS LOCATED IN OR BROUGHT INTO THE CONFINED SPACE: * Required

EQUIPMENT LOCATED IN OR BROUGHT INTO THE CONFINED SPACE:* Required

Potential Hazards: Hazardous Atmosphere* Required

None
Flammable
Toxic
Irritant
Corrosive
Oxygen-Deficient (<19.5%)
Oxygen-Enriched (>23.5%)
Other

Hazardous Atmosphere: If other, please describe* Required

Physical Hazards: If other, please describe* Required

Part B. Hazard Controls

Is Lockout/Tagout Required?* Required

If yes, list isolation point(s):* Required

Are GFCI’s required on electrical equipment?* Required

Is explosion-proof equipment required?* Required

Are barriers required?* Required

Is communication equipment required?* Required

Are a telephone or two-way radio for summoning rescue available?* Required

Is a fire extinguisher required?* Required

Fire extinguisher type* Required

Is an emergency shower/eye wash required?* Required

Is a full-body harness and retrieval line required?* Required

Is a tripod and winch required? * Required

Are SDS’s for all materials located in or brought into the confined space available?* Required

Have entrants and attendant been trained?* Required

Has attendant personnel been informed to remain continuously posted outside confined space?* Required

LIST ANY SPECIAL ENTRY AND/OR WORK PROCEDURES:* Required

LIST REQUIRED PERSONEL PROTECTIVE EQUIPMENT AND NON-ENTRY RESCUE EQUIPMENT:* Required

DESCRIBE MEANS OF COMMUNICATION BETWEEN ATTENDANT AND ENTRANT(S):* Required

Part E. Certification

I certify that the requirements of this permit have been met* Required

Entry Supervisor Name* Required

Entry Supervisor Phone* Required

Entry Supervisor Date* Required

Entry Supervisor Signature* Required

Attendant Name* Required

Attendant Signature* Required

Attendant Date* Required

Entrant Name* Required

Entrant Signature* Required

Entrant Date* Required

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files