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JOBSfTE S,4FETY WORKSHEET <br /> �- -� <br /> Date !/, s � ! �� Location �7 .�� .,7 viv �[/ <br /> Lead 2:� l �' Pre�Job Brieiing Time /^ � }< <br /> DescripfionofUdork: f4,j,ro�� ����� ��l� <br /> Sa�efy Inciden�s c Concerrts: <br /> � � I YES NIA <br /> . i reffic Control Plan—Attach TCP if modiiied f� <br /> , Conimed Space Ent —Attach Confined 5 ace Permit �/ <br /> Unconirolled EneraV—Attach Lockout Taqout • l� <br /> Boom Truck Used–Attach LiN plan if needed � <br /> Overhead liftinq—Inspect riqqin beiore each use <br /> EI_ rical Hazards& Conlrols , / <br /> Overhead ❑ Under round ❑ Generator ❑ Permanent Wirinq �� <br /> Hot Work—Describe � � e/ <br /> Hazardous Materials Used ✓ <br /> Falls over 4 feef—Controlled b : �� <br /> �cavation Entry over 3 ieet deep <br /> Final Depth wdih Length �� <br /> ❑ Finn Form ❑ Sloping ❑ Trench Box ❑ Build•a-Box <br /> First Aid EquipmentlTraininglFire Eztinguisher�dust 6e Current <br /> Utilities Locafed: �'Water(blue ��ower red �yoas yellow �mmunication (oran e) ❑ other <br /> Communication tvith emerqenc res onders provided ❑ Radio Dis atch ❑ Phone 911 ❑ Ci�V Phone 9-911 <br /> Personal Protective E ui ment liqh-Vs g'(ead L'�£yes �-Ftearinq ❑Whole 6odv • �other <br /> Pre-Job Safet �fee�ing <br /> Name "� Assignment Name Assignment <br /> Je�'� �22r,11'�� �l �� <br /> J�/ Gll.l �v� �V <br /> Revised 12/12/17 <br />