You must have JavaScript enabled to use this form. Confined Space ID Email Date Time Permit Expires Date Permit Expires Time Purpose of Entry Potential Hazards Expected Please Select the Options Oxygen Deficiency Flammable Gases/Vapors Toxic Gases/Vapors Mechanical Hazards Electrical Shock Materials Harmful to Skin Engulfment Other Preparation Required Please Select the Options Notify affected departments of service interruptions Isolate supply/return; blanked-double valve, lock & tag Zero energy state (lock out/tag out all energy sources) Cleaned, drained, washed and purged Ventilation to provide fresh air Emergency response team available Employee informed of specific confined space hazards Procedures reviewed with each employee Atmospheric tests in compliance Attach hot work permit Notify EH&S Department Other Equipment Required for Entry Please Select the Options Respirator Supplied Air Breathing Apparatus Protective Clothing Hearing Protection Eye Protection Personal Atmosphere Monitor Communication Equipment Low Voltage Tools/Lights Ground-fault Interrupters Approved for Hazardous Environments Fire Extinguisher Harness/Lifeline Tripod/Retrieval Equipment Other Personal/Area Continuous Atmospheric Monitoring Equipment Model Calibrated by Date Calibrated Rescue Services Environmental Health & Safety Department Contact by campus telephone: 75179 Contact by public telephone: 909-537-5179 Radio Call Sign: Safety 1 University Police Department Contact by campus telephone: 911 Contact by public telephone: 909-537-5165 Radio Call Sign: Dispatch San Bernardino Fire Department/Paramedics Contact by public telephone: 911