TECH RESCUE STANDBY | Somerville Rescue

TECH RESCUE STANDBY REQUEST

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First name

Last name

Company, Agency, Group Etc.

Contractor making entry if different from above

Purpose of entry

Address

Date of Entry

Start Time

End Time

Total Event Duration

Will there be a permit for this entry? (If No, Please Explain)

Is there a pre-existing IDLH atmosphere? (If Yes, Please Explain)

Will there be a potential of an IDLH atmosphere? (If Yes, Please Explain)

Will the entrant be on breathing air during entry? (If Yes, Please Explain)

Are there any second points for access/egress?

Diameter, shape, orientation of access/egress point(s):

Total depth (horizontal/vertical) of space:

Means of access (i.e. man-way, tripod, ladder, etc.):

How many entrants will be entering simultaneously?

Other comments/descriptions:

Entry Supervisor or Foreman Name and Contact info

Chief Officer of In-House Rescue Team Name and Contact Info

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