Permit Request • CampusOptics

University of Texas at Tyler ~ 3900 University Blvd. ~ Tyler, TX 75099

UT Tyler campuses contain many areas that are considered a "confined space". A confined space is any area that meets the following criteria: 1) limited openings for entry and exit, 2) the space is not intended for continuous human occupancy, and 3) the space is large enough for you to enter and conduct work. Confined spaces include, but are not limited to, tanks, vessels, vaults, pits, manholes, tunnels, equipment housings, ductwork, pipelines, etc. All work that is to be done by UT Tyler Facilities or contractors must have a permit completed by EH&S.

Emergency Contacts:

Environmental Health and Safety: (903)-566-7011
UT Tyler Emergency Dispatch: (903)-566-7300
Physical Plant: (903)-566-7431

Requester

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Confined Space Entry

Purpose for Entry: * Required

Employees Entering:* Required

EXPECTED HAZARDS

Hot Equipment* Required

Corrosive Materials* Required

Flammable Materials* Required

Open Drain* Required

Spilled Liquid* Required

Standing Water* Required

Pressure Systems* Required

Spark Producing Operations* Required

Welding, Brazing, Open Flame* Required

Drifting Vapors from Adjacent Sources* Required

Other:

PRECAUTIONS TAKEN

Has the procedure been approved by EH&S?* Required

Has all testing/monitoring equipment been tested/calibrated?* Required

Was the space tested for flammable, O2 and toxins? (Attach Air Sample Data)* Required

Were hazards pertaining to the space explained?* Required

Were emergency and rescue procedures explained?* Required

Are hazardous lines isolated, disconnected, blinded or blocked off?* Required

Are all electrical switches locked and tagged?* Required

Is communication equipment available/procedures explained?* Required

Is lighting, ladders, barrier/shields, or other necessary equipment available?* Required

Are the tripod, rescue lines, and harnesses/safety belts available?* Required

Is necessary protective equipment available?* Required

Is purging and ventilation required?* Required

Is forced air equipment working properly and from a clean supply?* Required

Has forced air been supplied for the required time before entry?* Required

Have other documents (Hot Work/LOTO/Fire System Shutdown) been completed? (If required)* Required

Air Sampling Data

Sampling Equipment Used:

Serial #:

Last Calibration Date:

Used By:

Air Sampling Data Before Entry

Time of reading

Oxygen % :* Required

Flammability % (LEL) :* Required

Hydrogen Sulfide :* Required

Carbon Monoxide :* Required

Air Sampling Data During Entry

Time of reading

Oxygen % :* Required

Flammability % (LEL) :* Required

Hydrogen Sulfide :* Required

Carbon Monoxide :* Required

Supervisors and Attendants

EH&S Representative:

EH&S Representative Phone:

Entry Supervisor:

Entry Supervisor Phone:

Attendant(s):

Attendant(s) Phone:

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files