Wexcon Inc. | Alternate Space Form

Assessment Date

Space Information

Job Name

Job Number

Numerical Space Designation

Space Marked

Yes

No

Entry Controlled

Yes

No

Signage

Yes

No

Barriers

Yes

No

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Hazard

Oxygen Deficiency: Less than 19.5%
Oxygen Enrichment: More than 23.5%
Flammable Gases or Vapors: More than 10% LEL
Toxic Gases or Vapors: More than PEL
Airborne Combustible Dusts: Meets/ Exceeds LFL

Test Result

Time

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ATMOSPHERIC HAZARDS MUST BE CONTINUALLY MONITORED DURING SPACE OCCUPANCY. VENTILATION MUST BEGIN BEFORE OCCUPANCY AND CONTINUE UNTIL WORK IS COMPLETED.

Ventilation Begun

Time Hazard Cleared

Test Result

Time Entered

Test Result

Time Exited

Ventilation Stopped

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Section

I certify that I have conducted an alternate space assessment of the above designated space. To the best of my knowledge, I believe the information contained herein to be true and accurate as of the time of the assessment.

*

I agree, and the alternate form is complete

I agree, and the alternate form is not yet complete

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Alternate Space Form

Space Information

Atmospheric Hazards Assessment

Ventilation Actions

Section