Confined Space Entry Form

POST AT ENTRY TO SPACE

General Information

Name of Confined SpaceDate

Purpose of EntryConfined Space #

Area / Unit and LocationJob / Project #

Pre-Entry Evaluation

Use job hazard assessment (JHA) to identify required PPE & implement safeguards.

Special precautions, procedures or historical data for this space:

Is a heat stress evaluation required?YesNoIf yes, air temperature (F):>120 F: ventilate until temp lowers

Initial Atmospheric Testing

Note: If initial test results exceed levels listed below, ventilate for 15 minutes, stop ventilation, retest.

#	Tested By(initials)	Date	Time	O2 >19.5% &O2 <23.5%	LEL<10%	CO<35 PPM	H2S<10 PPM	Other gas(specify / level)
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Gas monitor ID / last bump test:Retests due every:

Reclassification Checklist

Place a checkmark under a column to the right. Consider actual or potential hazards.

	Hazard can be eliminated	Hazard cannot be eliminated	Not applicable
Atmospheric hazards
Engulfment hazards
Converging walls or sloping floors (entrant could be trapped or asphyxiated)
Any other serious safety hazard (describe below)
Any other serious health hazard (describe below)
Ventilation for atmospheric control	Natural	Mechanical	N/A
Ventilation for comfort (odor, temperature, etc.)	Natural	Mechanical	N/A
Where hazards are regulated by specific OSHA standards, those hazards, in themselves, would not cause a space to be a permit-space. As long as the requirements of the applicable OSHA standard are met and entrants are ultimately protected from the applicable hazards, those hazards may be considered eliminated.	SPACE MAY BE RECLASSIFIED NON-PERMIT	USE PERMIT-REQUIRED PROCEDURE

Describe other hazards:

Other:

Choose a classification in the checklist above (the green or pink box in the last row). A permit-required space opens pages 2 and 3.

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Confined Space Entry Form

Confined Space #DateLocation

Entry Cancellation

All personnel have exited the space.

Entry Supervisor (sign):

Print name:

Time:Date:

Notes (debriefing with client / plant representative, incidents, near misses, corrective actions):

Liquidmetal Industrial Solutions | Confined Space Entry Form | Rev. 10/2026Page 2 of 5

Confined Space Entry Form

Entry Supervisor / Attendant / Entrant Continuation SheetConfined Space #

Transfer of Entry Supervisor

New Entry Supervisor (sign):

Print Name / ID:Date/Time:

Confined Space Permit Roster

Attendant (print):Employee ID:Date/Time:

AUTHORIZED ENTRANTS

Print Name	Employee ID	Date	Time In	Time Out	Time In	Time Out	Time In	Time Out	Time In	Time Out

Give this form to the Entry Supervisor at end of shift or when work is complete.

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Confined Space Entry Form

Atmospheric Testing Log

Confined Space #DateLocation / Unit

Entry SupervisorGas monitor IDLast bump test

Acceptable: O2 >19.5% & <23.5% | LEL <10% | CO <35 PPM | H2S <10 PPM. If exceeded, ventilate 15 min, stop ventilation, retest.

#	Date	Time	Test Location(top / mid / bottom)	O2 %19.5-23.5	LEL %<10	CO PPM<35	H2S PPM<10	Other gas(specify)	Pass / Fail	Tested by(initials)
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Confined Space Entry Form

Entry / Entrant Log

Confined Space #DateLocation / Unit

Entry SupervisorAttendant

Every entrant signs IN before entering and OUT upon exit. Attendant verifies headcount at all times.

#	Print Name	Company / ID	Date	Time In	Time Out	Entrant Initials	Attendant Initials
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