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Interpretation(
s)
Time
Oxygen
Explosive
Toxic
________
________%
________% L.F.L.
________PPM
N/A
( )
( )
Yes
( )
( )
No
( )
( )
4. Ventilation Modification:
Mechanical
Natural Ventilation only
N/A
( )
( )
Yes
( )
( )
No
( )
( )
Yes
No
( )
( )
N/A
Yes
No
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
Oxygen
Oxygen
Explosive
Explosive
Toxic
Toxic
____%
____%
____%
____%
____%
____%
Time
Time
Time
Time
Time
Time
____
____
____
____
____
____
TIME
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_______
SPACE
CHECK #
ENTRANT(S)
__________ _______
SPACE
ENTRANT(S)
__________
CHECK #
_______
______________
_______
__________ _______
__________
_______
SUPERVISOR AUTHORIZING - ALL CONDITIONS SATISFIED____________________
DEPARTMENT/PHONE ___________________________
AMBULANCE 2800 FIRE 2900
Safety
4901 Gas Coordinator 4529/5387