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JOF�SITF SAFETY WORKSHEET � <br /> Route to Safety within 4 days <br /> Ev <br /> - _ - - <br /> - - - - <br /> Date l, f Z, -o L / - _ __ Location �l_�__ C� _LG._��«' I <br /> Name !��_lS-o — - - Job # j�j a � p� Z� � <br /> � - - - <br /> Start Time_� ��,_� _ _ End Time _J�"3-O ___ _ <br /> Description of Work t9�{-b.� �� Z �r �✓�,�`�- S�'✓`�� �-� � ��w-�c c � <br /> �-{� e..�s l-� ,.._t,t___ (�'y" }�- tJ C Su-� . t('� <br /> �(all abovc bold linc is NIA,you do nol necd lo compicic this form YES NIA <br /> TrafGc Conlrol Required—l11�,�ch TCP i(modified <br /> G.zcavation Enlry ovr.r 3(ee�decp ❑ Nolify Dispalr.h <br /> C /P � � i <br /> final Deplh--�--- Widih- -- LengGi—�ij —- <br /> �] Shorinc� ❑ Sloping ❑ Trench Oox / <br /> Confinrd Space[Nry—Allach Confined Spac^Papen•:oik ❑ Noti(y Dispatch <br /> Uncontmlled�ncrgy—Allach Lockout Form <br /> Ulililies Localed I 10-foot minimum overhead cleamnce Irom overhead ower _�' _ <br /> Cranr.s 8 Rig9inq—Inspeclr.rl f3efore Use _____ �� <br /> Palis over 4 leel are conlralled <br /> Communicalion�vith mnergcnc .,pondcr�provided <br /> ❑ Radio�isp:dr.h Plionc�J11 __ ( �_�Phone 9-911- ------ ----- <br /> Firsl Aid Equpment/TraininglFire Exlinguisher Must bc Currenl _ <br /> I.is�Eleclrical Hazards&CaNrols(GfCI) <br /> List Hazardous Matcrials in Usc <br /> Lisl Power Tools <br /> I_is1 lir,avy Equipmenl(vr,hidc number) (l�E� G� _ <br /> Lisl Personal Proleclive[quipmenl W i-Vis - ard lial �eanny Pro�eclion <br /> ❑ Chain Saw Chaps Eye/Pace ❑ Res u�r ❑ <br /> Personnel On-�;ite <br /> Namc Assignmenl Name Assignmenl <br /> —/-lr-` -E� — <br /> ���^C�,!__—���J_-- - <br /> l�'�l_�`J — <br /> ��Y�v ---- -- -- — - -- — — ----- <br /> rz,:�•����r,nros �� <br />