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1908 MADISON ST 2016-01-01 MF Import
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1908 MADISON ST 2016-01-01 MF Import
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Last modified
4/13/2017 8:38:29 PM
Creation date
2/17/2017 10:01:52 PM
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Address Document
Street Name
MADISON ST
Street Number
1908
Imported From Microfiche
Yes
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Date(s) of work: <br />EXCAVATION/TRENCHING SAFETY CffECKI:IST <br />� - / � - J,5 Woric order # <br />Location of work: ��A �� S e��- ��^ r r^ r r c r� I .�— <br />Is a"Competent Person", as defined in WAC 296-I55-650, in chazge of job? .......................... Yes �No ❑ <br />Has Dial-A-Dig been called? ........................ <br />Dial-A-Dig number <br />Date & Time Dial-A-Dig <br />Are traffic control devices in place? ............ <br />Is trench/evacuation on the toe of a hill, slope, or near a retaining wall?.... <br />(If yes, consult supervisor or engineer for recommendations.) <br />If trench/excavation is less than 4 feet deep aze sides stable? ................................ <br />(If not, then trench/excavation must be shored.) <br />................ Yes �No ❑ <br />Yes'� No � <br />Yes ❑ No � <br />..,... Yes�No � <br />If trench is more than 4 feet deep is shoring in use? .................................. .�1.. ........................ Yes � No � <br />s shorin rated for depth of trench/excavation? .....................�/••�•••••••••••••••� •••••••••• 1'es � No � <br />I g <br />Is tabulated data for the shoring on the job site? ............................................................. Yes [] No � <br />Are spoil piles and other material stored at lease 2 feet from the edge of the ....... <br />trench/excavation? <br />Is water removed from the bottom of the trench/excavation? <br />Yes�No � <br />Yes'�No ❑ <br />. . � • � i ..................... Yes No <br />Is a ladder available for entry/exrt from trencb, excavation .................... .q,...// ❑ ❑ <br />/ <br />I� � i Yes No <br />Does it extend 3 feet above top of trench? ................................:..:..... :l:., ........................ Q ❑� <br />Is it secured at the to � ...................:.:.... �.................................. Yes No <br />p ...................................... � Yes [J No ❑ <br />Has it been inspected for defects/problems today .......................................................... <br />Is there a means of communication with rescuers in the event of an accident/problem? ........... YeS'�No ❑ <br />� Are the open sides of the trench/excavation barricaded, or protected, to prevent falls% ............. Yes'��No ❑ <br />Is there is a possibility of hazazdous atmospheres in the trench/excavation? ............................. Yes [�' No� <br />(Such as from leaking gas mains, neazby industries, work over landfills, or other situations.) <br />.. . ............ . . .: .. ... . . Yes � No ❑ <br />If yes, is a calibrated gas detector in use? ................... .. . `^ •, <br />If yes, is a means of retrieval available fo: workers in the trenchle�c vation? .............. Yes ❑ No ❑ <br />Are all workers on site awaze of safety requirements for workers in irenches/excavations? ..... Yes��No ❑ <br />1 � /% c� � <br />Signature of Crew Leader: � 16�'���� ✓`�� `P�t"�-� Date: `�- �-? - �� <br />vow��s:noao¢n�t�•�wi vvs 1 <br />
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