University of Kentucky
CONFINED SPACE EVALUATION - ENTRY PERMIT SYSTEM
PART 4 - ENTRY PERMIT

PART 4
(Post at entrance for duration of entry operation)

This confined space has been designated a Permit Required Confined Space (PRCS). This space may only be entered by personnel who have been specially trained to work in PRCS in accordance with the University of Kentucky Confined Space Entry Program. Entry operations may proceed only under the direction on an entry supervisor. A specially trained attendant shall remain outside the PRCS for the duration of the entry operation.
HAZARDOUS CONDITIONS IDENTIFIED DURING EVALUATION

¨

 Atmospheric Hazards
Decribe: ____________________________________________________
Acceptable Entry Conditions: ___________________________________
Prohibited Conditions: _________________________________________

¨

Physical Hazards
Describe: ____________________________________________________
Acceptable Entry Conditions: ____________________________________
Prohibited Conditions: __________________________________________
ADDITIONAL PERSONAL PROTECTIVE/SAFETY EQUIPMENT NEEDED

¨

SCBA Describe: __________________________________________
¨   Respirator Describe: __________________________________________
¨   Special Safety Equipment Describe: __________________________________________
¨   Other Describe: __________________________________________
PERMIT AUTHORIZATION
Permit #: _______________
Duration of Permit: _______
Date of Permit: __________
Authorized By:
Name: _______________________________
Title: ________________________________
Phone #: _____________________________
Signature: ____________________________
PERMIT CANCELLATION
Date:
_________		 Time:
________		 Canceled by:
_____________________________________________
 
Reason for Cancellation: ¨ Occurrence of Prohibited Condition
¨ Entry Operation Completed (Complete Part 5)
Part 3 | Confined Space Program