<table style="width:100%;">
<colgroup>
<col style="width: 3%" />
<col style="width: 16%" />
<col style="width: 19%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 25%" />
<col style="width: 5%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><strong>SECTION 1 Confined Space Location</strong></td>
</tr>
<tr class="even">
<td colspan="10">Confined Space Identification Number:      </td>
</tr>
<tr class="odd">
<td colspan="4">Site:      </td>
<td colspan="6">Date:      </td>
</tr>
<tr class="even">
<td colspan="4">Area:      </td>
<td colspan="6">Responsible IH/SE: (name/signature)      </td>
</tr>
<tr class="odd">
<td colspan="4">Bldg. or Grid Number:      </td>
<td colspan="6">Responsible Manager:      </td>
</tr>
<tr class="even">
<td colspan="4">Room:      </td>
<td colspan="6">Org. Number:      </td>
</tr>
<tr class="odd">
<td colspan="10">Physical characteristics and configuration of space:
     </td>
</tr>
<tr class="even">
<td colspan="10">     </td>
</tr>
<tr class="odd">
<td colspan="10">     </td>
</tr>
<tr class="even">
<td colspan="10"><strong>SECTION 2 Confined Space Assessment (Check YES
or NO)</strong></td>
</tr>
<tr class="odd">
<td>1.</td>
<td colspan="9">Assess if the space meets <strong>all</strong> of the
following criteria to be considered as a confined space.</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"></td>
<td><strong>YES</strong></td>
<td><strong>NO</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7"><p>a. Large enough and so configured that employee can
bodily enter and perform assigned work;</p>
<p>and</p></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="7">b. Limited or restricted means for entry or exit;
and</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">c. Not designed for continuous employee occupancy.</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>2.</td>
<td colspan="7">Is the space a confined space?</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>3.</td>
<td colspan="9">Assess if the confined space has <strong>one or
more</strong> of the following characteristics to be considered a
permit-required confined space.</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7">a. Contains or potential to contain a hazardous
atmosphere (If YES, specify in Section 3);</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">b. Contains a material that has the potential for
engulfing an entrant (If YES, specify in Section 3);</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"><p>c. Has an internal configuration such that an entrant
could become trapped or asphyxiated (If YES,</p>
<p>specify in Section 3);</p></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">d. Contains any other recognized serious safety or
health hazard (If YES, specify in Section 3).</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>4.</td>
<td colspan="7">Is the space a permit-required confined space? (If NO,
complete Section 4)</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>SECTION 3 Hazard Evaluation Checklist - Check
YES, NO, or N/A for existing/potential hazards in this
space</strong></td>
</tr>
<tr class="even">
<td colspan="3"><strong>HAZARD</strong></td>
<td colspan="2"><strong>YES</strong></td>
<td><strong>NO</strong></td>
<td><strong>N/A</strong></td>
<td colspan="3"><strong>COMMENTS</strong></td>
</tr>
<tr class="odd">
<td>1.</td>
<td colspan="2">[O<sub>2</sub>] below 19.5 or above 23.5%</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3">     </td>
</tr>
<tr class="even">
<td>2.</td>
<td colspan="2">Combustible atmosphere</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td>3.</td>
<td colspan="2">Toxic gases/vapors</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3">     </td>
</tr>
<tr class="even">
<td>4.</td>
<td colspan="2">Dust, fumes, mist</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td>5.</td>
<td colspan="2">Inert/O<sub>2</sub> displacing gases/vapors</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3">     </td>
</tr>
<tr class="even">
<td>6.</td>
<td colspan="2">Unfavorable ventilation</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td rowspan="2">7.</td>
<td rowspan="2">Process (specify)</td>
<td>     </td>
<td colspan="2" rowspan="2"></td>
<td rowspan="2"></td>
<td rowspan="2"></td>
<td colspan="3" rowspan="2">     </td>
</tr>
<tr class="even">
<td></td>
</tr>
</tbody>
</table>

+---+----------+-------------+----+----+----+-------------------------+
| 8 | R        |             |    |    |    |                         |
| \ | adiation |             |    |    |    |                         |
| . | (        |             |    |    |    |                         |
|   | specify) |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
|   |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| # |          |             | *  | ** | *  | **COMMENTS**            |
|   |          |             | *Y | NO | *N |                         |
| H |          |             | ES | ** | /A |                         |
| A |          |             | ** |    | ** |                         |
| Z |          |             |    |    |    |                         |
| A |          |             |    |    |    |                         |
| R |          |             |    |    |    |                         |
| D |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| 9 | Nearby   |             |    |    |    |                         |
| \ | m        |             |    |    |    |                         |
| . | achinery |             |    |    |    |                         |
|   | o        |             |    |    |    |                         |
|   | peration |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| 1 | Tem      |             |    |    |    |                         |
| 0 | perature |             |    |    |    |                         |
| \ | extremes |             |    |    |    |                         |
| . |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| 1 | Engul    |             |    |    |    |                         |
| 1 | fment/en |             |    |    |    |                         |
| \ | trapment |             |    |    |    |                         |
| . |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| 1 | Trippi   |             |    |    |    |                         |
| 2 | ng/falls |             |    |    |    |                         |
| \ |          |             |    |    |    |                         |
| . |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| 1 | El       |             |    |    |    |                         |
| 3 | ectrical |             |    |    |    |                         |
| \ |          |             |    |    |    |                         |
| . |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| 1 | Special  |             |    |    |    |                         |
| 4 | rescue   |             |    |    |    |                         |
| \ | consid   |             |    |    |    |                         |
| . | erations |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| 1 | Space    |             |    |    |    |                         |
| 5 | tied to  |             |    |    |    |                         |
| \ | other    |             |    |    |    |                         |
| . | areas by |             |    |    |    |                         |
|   | lines,   |             |    |    |    |                         |
|   | tunnels, |             |    |    |    |                         |
|   | etc.     |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| 1 | Bi       |             |    |    |    |                         |
| 6 | ological |             |    |    |    |                         |
| \ |          |             |    |    |    |                         |
| . |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| * | **Other  |             | *  | ** | *  | **COMMENTS**            |
| * | (sp      |             | *Y | NO | *N |                         |
| 1 | ecify)** |             | ES | ** | /A |                         |
| 7 |          |             | ** |    | ** |                         |
| . |          |             |    |    |    |                         |
| * |          |             |    |    |    |                         |
| * |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
|   |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
|   |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
|   |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| * |          |             |    |    |    |                         |
| * |          |             |    |    |    |                         |
| S |          |             |    |    |    |                         |
| E |          |             |    |    |    |                         |
| C |          |             |    |    |    |                         |
| T |          |             |    |    |    |                         |
| I |          |             |    |    |    |                         |
| O |          |             |    |    |    |                         |
| N |          |             |    |    |    |                         |
| 4 |          |             |    |    |    |                         |
| . |          |             |    |    |    |                         |
| N |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| - |          |             |    |    |    |                         |
| P |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| m |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| t |          |             |    |    |    |                         |
| C |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| f |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| d |          |             |    |    |    |                         |
| S |          |             |    |    |    |                         |
| p |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| c |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| . |          |             |    |    |    |                         |
| I |          |             |    |    |    |                         |
| m |          |             |    |    |    |                         |
| p |          |             |    |    |    |                         |
| l |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| m |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| t |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| c |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| s |          |             |    |    |    |                         |
| s |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| y |          |             |    |    |    |                         |
| w |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| k |          |             |    |    |    |                         |
| c |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| t |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| l |          |             |    |    |    |                         |
| s |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| s |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| t |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| d |          |             |    |    |    |                         |
| b |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| l |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| w |          |             |    |    |    |                         |
| . |          |             |    |    |    |                         |
| * |          |             |    |    |    |                         |
| * |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| C |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| m |          |             |    |    |    |                         |
| m |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| t |          |             |    |    |    |                         |
| s |          |             |    |    |    |                         |
| : |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| > |          |             |    |    |    |                         |
|   |          |             |    |    |    |                         |
|   |          |             |    |    |    |                         |
|   |          |             |    |    |    |                         |
|   |          |             |    |    |    |                         |
|   |          |             |    |    |    |                         |
|   |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+
| C |          |             |    |    |    |                         |
| C |          |             |    |    |    |                         |
| : |          |             |    |    |    |                         |
| B |          |             |    |    |    |                         |
| u |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| l |          |             |    |    |    |                         |
| d |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| g |          |             |    |    |    |                         |
| / |          |             |    |    |    |                         |
| F |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| c |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| l |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| t |          |             |    |    |    |                         |
| y |          |             |    |    |    |                         |
| M |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| g |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| C |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| f |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| d |          |             |    |    |    |                         |
| S |          |             |    |    |    |                         |
| p |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| c |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| O |          |             |    |    |    |                         |
| w |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| d |          |             |    |    |    |                         |
| I |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| d |          |             |    |    |    |                         |
| u |          |             |    |    |    |                         |
| s |          |             |    |    |    |                         |
| t |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| l |          |             |    |    |    |                         |
| H |          |             |    |    |    |                         |
| y |          |             |    |    |    |                         |
| g |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| n |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| / |          |             |    |    |    |                         |
| S |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| f |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| t |          |             |    |    |    |                         |
| y |          |             |    |    |    |                         |
| A |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| a |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| p |          |             |    |    |    |                         |
| r |          |             |    |    |    |                         |
| o |          |             |    |    |    |                         |
| j |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| c |          |             |    |    |    |                         |
| t |          |             |    |    |    |                         |
| f |          |             |    |    |    |                         |
| i |          |             |    |    |    |                         |
| l |          |             |    |    |    |                         |
| e |          |             |    |    |    |                         |
| . |          |             |    |    |    |                         |
+---+----------+-------------+----+----+----+-------------------------+