1403 MAPLE ST 2016-01-01 MF Import

EXCAVATION/TRENCHING SAFETY CHECKLIST Date(s) of work: �> — � Wc�rk order# 9 �i- Location of work: �Y�, ` n l �� I f' — Is a"Competent Person", as defined in�VAC 296-155-650, in chazge of job?..........................Yes ❑ No � HasDial-A-Dig been called?......................................................................................................Yes ❑ No`�- Dial-A-Dig number Date &Time Dial-A-Dig Done Are tra�c control devices in place?........................................................................................... Yes 0 No'�. Is trench/evacuation on the toe of a hill, slope, or neaz a retaining wall?...................................Yes ❑ No� (If yes, consu;i supervisor or engineer for recommendations.) If trench/excavation is less than 4 feet deep aze sides stable?..................................................... Yes�],No � (If not, then trench/excavation must be shored.) .........................:........:.......................... If trench is more than 4 feet deep is shoring in use?...... �-�j �� Yes ❑ No ❑ /.!...�M......................Yes No Is shoring rated for depth of trench/excavation?............�;L. ...... , ❑ � Is tabulated data for the shoring on the job site?..................................�......................... Yes❑ No ❑ Are spoil piles and other material stored at lease 2 feet from the edge of the........................... Yes'��No ❑ uench/excavation? Is water removed from the bottom of the trench/excavation?.....................................................Yes�`No ❑ • ................................... Yes No Is a ladder avuilable'.br entry/exit from trench/excavation?...................J � ❑ ❑ Does it cxtend 3 feet above top of trench?........................��...�..�........................... Yes ❑ No � IS it secured at the top?....................................................��,, %..%:................................. Yes � No � Has it been inspected for defects/problems today?........:................................................ Yes � No 0 Is there a means of communication with rescuers in the event of an accidenUproblem?........... YesT].. No ❑ Are the open sides of the trench/excavation barricaded, or protected,to prevent falls?............. Yes ❑ No'� Is there is a possibility of hazardous atmospheres in the trench/excavation?............................. Yes � No'Q (Such as from leaking gas mains,nearby industries,work over landfills, or other situations.) • � ' . . . . ........... Yes No If yes, is a calibrated gas detector in use?................:.............. ...�..,....�.,.._.. . ... .. O ❑ If yes, is a means of retrieval available for workers in the treqcfi/exCauat�on? .............. Yes � No � Are all workers on site aware of safety requiremenFs for workers in trenches/excavations?..... Yes-,0_ No ❑ Signature of Crew Leader: i` %C z�L�' =.` „�`%'? ._ Date: `� � ' �� roan�s nnooicni.t�n�wuros) •