Alternate Entry Certificate

CAUTION!!! THIS IS NOT A CONFINED SPACE ENTRY PERMIT.

This form must be filled out and signed by a Confined Space Entry Supervisor or a Qualified Health and Safety Professional. An Alternate Entry Certificate is valid for a single shift. The following evaluation is consistent with OSHA 29 CFR 1910.146(c)(5).

Entry Supervisor (or Health and Safety Professional) - Complete the following:

Space ID: 396003
Location: GABLES NORTH N/A
Yes/No Comments/Results
Is an actual or potential hazardous atmosphere the ONLY hazard associated with this confined space?
The entrant will not perform any hot work or use any hazardous chemicals that present a respiratory hazard. (If either or true, refer to permit entry procedures.)
Is the Entry Supervisor trained in operation of the gas monitor in use?
Has a air monitor functional test been performed this shift on the monitor to be used in accordance with the manufacturer's instructions?
Has a ventilation blower in good working condition been set up to ventilate the space? Has the Entry Supervisor calculated the appropriate purge time and allowed the space to be purged of hazardous air contaminants prior to air testing? Does the blower achieve 20 air changes per hour?
Has the atmosphere of the confined space been tested prior to entry? Were results within acceptable limits (Oxygen between 19.5% to 23.5%; Combustible gas less than 10% LEL, Hydrogen Sulfide less than 10 ppm, Carbon Monoxide less than 35 ppm)? (Document air measurements in comments section.)

*Entry Supervisor must notify the Office of Environmental Health and Safety of the scheduled entry and alternate procedures prior to entry activities.

If the answer to any of the above question is "No" then alternate entry procedures cannot be used and entry must be performed under permit conditions.

A copy of this certificate must remain at the entry site for the duration of the entry or shift, whichever is shorter. This certificate is considered valid for no greater than 1 shift or 8 hours. A copy of this form must be provided to the UNH Office of Environmental Health and Safety upon completion of entry into the space. The department overseeing the entry is responsible for maintaining a copy of this form on file for a minimum of 1 year.

 

Name of Supervisor or Health & Safety Professional: