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Sample company (fictional) · Confined Space PermitsDraft generated Oct 30, 2026

Confined space entry permit

Oct 10, 2026

Record

CompanySample company (fictional)
TradeConfined Space Permits
Entry permitOct 10, 2026

Utility

NameNorthgate Fabrication
Emailavery@example.com
Phone555-0110
Address120 Foundry Rd, Springfield

Facility

NameAvery Lund
Address120 Foundry Rd, Springfield
Location44.05, -123.09

Permit space

Space IDSpace ID 1
TypeManhole
ClassificationPermit-required
Location at the facilityNorth bay
Danger sign or other warning postedYes

Entry permit

DateOct 10, 2026
Authorized fromOct 10, 2026
Authorized untilMay 18, 2027
Purpose of the entryRecorded on site.
Authorized entrantsRecorded on site.
Attendants, by nameAttendants, by name 1
Entry supervisor, by nameEntry supervisor, by name 1
Hazards of the spaceRecorded on site.
Isolation and hazard controls before entryRecorded on site.
Acceptable entry conditionsRecorded on site.
Pre-entry test timeOct 10, 2026
Pre-entry testerPre-entry tester 1
Gas monitor usedUN-4100
Rescue and emergency services, and how to call themRecorded on site.
How entrants and attendants keep in contactHow entrants and attendants keep in contact 1
Equipment providedRecorded on site.
Other permits issued for this entryOT-4100
Vertical space more than 5 feet deepYes
Retrieval systemUsed
Mechanical retrieval deviceMechanical retrieval device 1
StatusBeing prepared
Why it was cancelledWork completed
Cancelled onOct 10, 2026
Cancelled byAvery Lund

Pre entry

Danger sign or barrier at the openingPass
Isolation on the permit done: lockout, blanks, lines brokenPass
Ventilation running, drawing clean airPass
Traffic and pedestrian barriers upPass
Harness and retrieval line on each entrant, tripod and winch setPass
Rescue service reached and the way to call them testedPass
Radio or voice contact checked between entrant and attendantPass
Entrants shown the test resultsPass
Signed permit posted at the openingPass

Readings

ReadingValueResult
Oxygen, pre-entryNot takenRecorded
Oxygen, pre-entry range
29 CFR 1910.146(b) hazardous atmosphere (Cornell LII) (https://www.law.cornell.edu/cfr/text/29/1910.146), checked 2026-10-29		19.5 to 23.5 percentPass
Flammable gas, pre-entry, percent of LFL (LEL on most meters)
29 CFR 1910.146(b) hazardous atmosphere (Cornell LII) (https://www.law.cornell.edu/cfr/text/29/1910.146), checked 2026-10-29		6 % LFLPass
Hydrogen sulfide, pre-entryNot takenRecorded
Carbon monoxide, pre-entryNot takenRecorded

Air test during entry

Time testedTesterTestOxygenFlammable gasHydrogen sulfide
Oct 10, 2026Tester 1Periodic1 %1 % LFL1 ppm
Sep 22, 2026Tester 7Periodic43 %5 % LFL5 ppm

Close out

Every entrant out and countedPass
Equipment out and the opening closedPass
Permit cancelled, problems written on itPass

Signature

The signature drawn on the phone at the job prints here.