3802 HOYT AVE 2016-01-01 MF Import

Date{s) of work: Location of work: EXCAVATION/Cl2ENCHING S.A�ETY CHECKLIST --6� 9� �� � Work order Is a"Competent Person", as defined in WAC 296-155-650, in chazge ofjob'? Has Dial-A-Dig been called? .................. ..... Yes'��'j-No � ...... Xes � No [�- Dial-A-Dig number Date & Time Dial-A-Dig Done Are U�affic control devices in place? ........................................................................................... Yes �No � Is trench/evacuation on the toe of a hill, slope, or neaz a retaining wall? ................................... Yes � No � (If yes, consult supervisor or engineer for recommendations.) If trench/excavation is less than 4 feet deep aze sides stable? (If not, then trenchlexcavation must be shored.) If `renct, is more than 4 feet deep is shoring in use? ................................... � Is shoring rated for dept;� of trench/excavation? ...........: .. .�j. :�. �7.. Is tabt:lated data for the shoring on the job site? .......... ..................... Are spoil piles and other material stored at lease 2 feet from the edge of che trench/excavation? Is water removed from the bottom of the trench/excavation? Yes� No ❑ ........................... Yes � PJo � Yes � No � Yes � ?�Io � ........... Yes � No � ............ Yes �No � Is a ladder availaUle for entry/exit from trench/excavation? ...................c....c... ......................... Does it extend 3 feet above top of trench? ............................. ��i� .. i......................... Isit secured at the top? .........................................................b:........................................ Has it been inspected for defec[s/problems today? ......................................................... Is there a means of communication with rescuers in the event of an accidendgroblem? Yes � No � Yes � No � Yes � No � Yes � No p ." i: �' ■ • Are the open sides of the trench/excavation barricaded, or protected, to prevent falls? ............. Yes��No � Is there is a possibility of hazazdous atmospheres in the trench/excavation? ............................. Yes � No'0 (Such as from leaking gas mains, nearby industries, wo:k over landfills, or other situations.) If yes, is a calibrated gas detector in use? .............................................................. .. Yes � No [j If yes, is a means of retrievai available for workers in tlie trench/excavation? ..��... Yes � No � Are all workers on site aware of safety requirements for workers in trenches/excavations? ..... Yes �- No � �' � 7 Signature of Crew Leader. �y�u�N.l�h� -%� �uli>1f)1�1� Bate: �;�-` 6" y S ron.us unwic�;��nia�urvs>