1407 MAPLE ST 2016-01-01 MF Import

�.._ �-— -- .. -- SI10W NORTH • SHUT-0FF LOCATION w/DIM M:/ovrc/seavicE ccw i2/ea . . - ' � . ' ' - : • EXCAVATION/fRENCHING SAFETY CHECKLIST . . • , , � �. . . •� � � � � . Date(s) ofwork: �`- j Workorder# �. =�- —�-- � � a�� , 7 �.� � l� SI- _ L. —i— — —jE l�--� _ � � . Location of wcrk: � =I � • ^ ,1 I i t I • � � . Is a"Competent Person",as defined in WAC 296-155-650, in chazge of job?..........................Yes�No ❑ / v � ' ' ........................................ .............................Yes�No ❑ . Has Dial-A-Dig been called?................................. r,�n .rz ,.; ' Date&Time Dial-A-Dig Done 31V�I 2id _;�______�___.— _ __________ ��_ ____ o 0 0 Dial-A-Dig number �--- �I l9fld � ' Are traffic control devices in place?...........................................................................................Yes❑ No-� � � . ii Is trench/evacuation on the toe of a hill, slope,or neaz a retaining wall?...................................Yes❑ o'Q- t,:, . i i �:: : � • . (If yes, consult supervisor or engineer for recommendations.) �s } i i; ti�: i I� XVY1.21 i�% . . If trench/excavation is less than 4 feet deep are sides stable7..................................................... Yes�No ❑ ; , i� • . NIN_6 11 . (If not,then trench/excavation must be st:ored.) , ' . . • • ............................Yes No ❑ . . . , '• If uench is more than 4 feet deep�s shonng m use?.............................�..J.... � . • •. . . . • I / - .................�/�. ..(�............................Yes�] No❑ w ' ' �� Is shoring rated for depth of trench/excavation?. • , � • � . ' Yes❑ No ❑ — t a . Is tabulated data for the shoring on the job site?............................................................. . . ; o O O O . . �• . .i0 J . ' . 6. ' �N d Are spoil piles and other material stored at lease 2 feet from the edge of the........................... Yes�No ❑ . i� trench/excavation? . � � : � � ;. .. . . . . . Is water removed from the bottom of the trench/excavation?..................................................... Yes�Z]�No � / : Is a ladder available for entry/exit from trench/excavation?.......................: ............................. Yes❑ No � " . . . �. � • . „ �. . Yes❑ No ❑ : 2i3A0� NIYI .Of .........;.��..�.....:.............................. . , . ' � . . • , Does it extend 3 feet above top of trench?............ .. yes ❑ No 0 ' � ' � ' ` : ........................:.............. � . .. . Is it secured at the top7............................... . . . � . . • • • . . . Has it been inspected for defects/problems today?......................................................... Yes ❑ No ❑ ; . . , � ,. :, . . . . O. � ........... • • . : Is there a means of communication with rescuers in the event of an accident/problem? Yes��No ❑ ', O . . . O O O Are the open sides of the t:ench/excavation barricaded, or prorecte d,to preven t f a l l s?.............Y es �_ No ❑ � . � • : . . : . . • .... . . .. . . . ..... Yes No. - . ' : � . . . Is there is a possibility of hazardous atmospheres �n the trencl�/excavation?...... . . . . . . . � -�'— • ' . . , ' (Such as from leaking gas mains, neazby industries,work over landfills, or other situatiotis.) � . .,: � ....Yes❑ No ❑ : : ....... ........................................... . • :. If yes, is a calibrated gas detecror in use?.. • APPL.. OR SERV ORD �$ J1 p2 C ilable for workers in the trench/excavation?...... .. .... Yes ❑ No ❑ ' • SERVI CE ADDRESS. �, iJ 1 ,�. � . . . . # � w t � � �. .� . � , � 5 eter �. ,� .. If yes, is a means of retrieval ava „ . � � • ,.. : : '•WATER. SERVICF ��ASBUILT ''� �. .; � .•d°te�� ':�" j nbe . , � ..... Y�s� No � - E� ET! - Are all workers on site awarc of safety requi�,ents for workers m trenches�excavations. _ _ .. . � -CITY �OF �EVERETT �',FUBLIC...�NORKS: DEPARTMEN7 .•. � 1 , �: __, . . � .. . . . . . . � . . . , . " �`' ' Date: ? j/ ��,-�;�� //.�.k � . � ' ' . . ' .. Signature of Crew Leader: l roanu�neooicn�anidr�s�