PERMIT-REQUIRED CONFINED SPACE Location of Confined Space:Space Number: Trade Shop: Purpose of Entry: Authorized Duration of Permit: Date: to Time: to Additional Permits (circle all that apply): Burning Welding Brazing Cutting Open Flame POSSIBLE HAZARDS PRESENT (circle all that apply): Oxygen deficiencyElectrical shock Oxygen enrichmentEngulfment Combustible dustPressurized Systems Materials harmful to skinFlammable gases or vapors Toxic gases or vaporsMechanical hazards OTHER (please describe): HOW ARE HAZARDS BEING ELIMINATED BEFORE ENTRY (circle all that apply): Lockout/TagoutDisconnecting(blanking) CleaningForced Air Ventilation OTHER (please describe): EMERGENCY SERVICE: USC POLICE DEPARTMENTTELEPHONE: AUTHORIZATIONS: Authorized Entry Employees: Authorized Attendant: Authorized Entry Supervisor: I certify that all required precautions have been taken and necessary equipment is provided for safe entry and work in the above listed confined space. Name(print): Signature: Date: EHS-F-014Page 1Issue Date: 7/8/03 Destroy Previous RevisionsApproved: _________

I INITIAL GAS CHECKS - BEFORE VENTILATION IS APPLIED % Oxygen-Top:Middle:Bottom: Must be between 19.5%-23.5% %LEL -Top:Middle:Bottom:Must be less than 10% CO ppm-Top:Middle:Bottom:Must be less than 35 ppm H2S ppm-Top:Middle:Bottom:Must be less than 10 ppm PERIODIC ATMOSPHERIC TEST RESULTS : Is forced air ventilation being applied? (circle)YESNO Instrument reading must be:%Oxygen between 19.5% and 23.5% % LEL lower than 10 % CO ppm lower than 35 ppm H2S ppm lower than 10 ppm Initial Time%Oxygen%LELCO ppmH2S ppmComments EHS-F-014Page 2Issue Date: 7/8/03 Destroy Previous RevisionsApproved: _________

SIGNATURE FORM FOR ENTERING A CONFINED SPACE This form must be used any time a Confined Space Entry Permit is used. The observer/attendent must keep this form at the entrance of the Confined Space. Each person who enters and exists the Confined Space must sign and record the time on this form. If a person exits the Confined Space in a location other than where the observer is located, he must immediately report and sign this form. NameTime INTime OUTSignature EHS-F-014Page 3Issue Date: 7/8/03 Destroy Previous RevisionsApproved: _________