Pasco County
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Confined Space Entry Permit

  1. CONFINED SPACE ENTRY PERMIT
  2. If an exact address is not available, use the nearest physical address.
  3. What task(s) are being completed?
  4. CONFINED SPACE ENTRY TEAM
  5. ENTRY SUPERVISOR
  6. Training Completed*
  7. ATTENDANT
  8. Training Completed*
  9. Please annotate names, phone numbers, and training status of all additional attendants.
  10. ENTRANT 1
  11. Yes or No*
  12. ENTRANT 2
  13. Yes or No
  14. ENTRANT 3
  15. Yes or No
  16. Please annotate names, phone numbers, and training status of all additional entrants.
  17. RESCUE SERVICES NOTIFICATION
  18. Pasco County Fire Rescue Dispatch
  19. PCFR Special Ops. Chief Lingo
  20. ADDITIONAL PERMITS
  21. PERSONAL PROTECTIVE & SAFETY EQUIPMENT UTILIZED
  22. Full Body Harness*
  23. Lanyard/Lifelines*
  24. Retrieval Hoisting Equipment*
  25. Hard Hat*
  26. Eye Protection*
  27. Hearing Protection*
  28. Gloves*
  29. Atmospheric Monitor*
  30. Non-Sparking Tools*
  31. Fire Extinguisher *
  32. First Aid Kit*
  33. Protective Clothing*
  34. ATMOSPHERIC MONITORING
  35. ATMOSPHERIC MEASUREMENT "BEFORE" SOURCE OF ISOLATION
  36. (>19.5% <23.5%)
  37. (< 10% of L.E.L.)
  38. CO
  39. H2S
  40. SOURCE OF ISOLATION AND VENTILATION
  41. Lock Out Tag Out*
  42. Forced Ventilation*
  43. Flushing*
  44. ATMOSPHERIC MEASUREMENT "AFTER" SOURCE OF ISOLATION
  45. (>19.5% <23.5%)
  46. (<10% of L.E.L.)
  47. CO
  48. H2S
  49. PERIODIC ATMOSPHERIC MEASUREMENTS
  50. (>19.5% <23.5%)
  51. (<10% L.E.L)
  52. CO
  53. H2S
  54. CLOSE THE JOB
  55. Call Fire Rescue*
  56. All Tools Accounted For*
  57. All Personnel Accounted For*
  58. Jeffrey Brockman O: 813-929-2755 x6933 C: 727-277-4781

    Safety Manager | Public Infrastructure

  59. Erica Williams O: 813-929-2755 x6908 C: 727-992-4438
    Safety Specialist | Public Infrastructure
  60. Aaron Pearson O: 813-929-2755 x6762

    Safety Specialist | Public Infrastructure

  61. Confined Space Entry Supervisor
    I understand and certify that this Confined Space Entry team has reviewed the work authorized by this permit and the information contained herein. All team members have been trained in accordance with OSHA 1910.146. This permit is not valid unless ALL sections are completed. This permit must be kept visible on the work site while the confined space entry is in progress. The permit is valid only for the duration of this job.
  62. Leave This Blank:

  63. This field is not part of the form submission.