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2. Protect yourself with a facemask, eye protection and rubber gloves if available. Do not <br />expose yourself if protective items are not available. <br />3. Only with protective items on should you attempt to provide first aid until emergency <br />personnel arrive. <br />CONFINED SPACE ENTRY <br />Example of a Lino Lakes form <br />CITY OF LINO LAKES <br />CONFINED SPACE ENTRY FORM <br />DATE DEPARTMENT <br />TIME LOCATION <br />LENGTH OF PERMIT M.H.# <br />YEARLY DAILY LIFT STATION <br />Not <br />Required Required <br />1. Unit Ventilated yes no <br />2. Oxygen Content 19.5 % Minimum Reading <br />3. Explosive Vapors Less Than 10 % Reading <br />4. Hydrogen Sulfide Less Than 10 ppm Reading <br />5. Protective Equipment <br />a. Harness Person Entering yes no <br />b. Lifeline Person Entering yes no <br />c. Rescue Line Tied Off yes no <br />d. SCBA Person Entering yes no <br />e. Five Minute Escape Capsule with Person Entering yes no <br />f. Tripod Set up yes no <br />6. Monitoring Meter on Person Entering yes no <br />7. Other Conditions (Specify) <br />Person(s) Entering <br />Watchperson(s) <br />Supervisor <br />(Signatures) <br />16 <br />