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JOBSITE SAFETY WORKSHEET <br /> Route to Safety within 4 days <br /> Ev <br /> - - _ _ — - - -- -- - <br /> Date 3 -(�, . o � _ - _ Location (a�jn � /<m.���:�.� - <br /> Name ' 1_ ��2�5�-- ---- - -- - Job # _2,cY:,n_^7 _02�Y—___ <br /> Start Time d �p p_ End Time <br /> Descri tion of Work , s Lu. �( /�zw L�� �� �S-3o_ <br /> P i - /' W �'L S-ei✓. c � � /'t �o«c..�e <br /> �'"( SC/'✓� G� �a c l�� c f S/i.✓ <br /> If all above I�old line is WA,you do nol need to complelc this tonn YES NIA <br /> IYalfic CoNrol Required—Allar.h iCl'il modificd � <br /> Gxcavation f_nlry avcr 3 Ir.r,l dceP s� ❑ Nolify Dispalch <br /> PinalDeplli---�y�� _ Width--- 3 / _ Lenclh—�/—_._.. <br /> J / <br /> �_� Shoring (J Sloping ❑ Trench Cfox <br /> Conlined Space f_nlry—AUadi Canfined Spnce Paperv�oik �] Nolify Dispalch �� <br /> Unconlrollr.d 6tcrqy—All:�r.h Lockoul Porm � <br /> Ulililies Loca�ed/ 10-fool minimwn ovahead clearance from ovr.rhead iower � <br /> Cranr,s 8 Riq�inJ c]—Ins�rf .c:Ial f3r.lorc Usc .� <br /> Palls over 4 fecl nrc conlrolled / <br /> Communir.alion wilh cnwrycncy .,ponders providcd <br /> (_�Radio DisP�dcli Phonc J1 I ❑ CitY Phunc 9�l I I--_--__-- <br /> First Aid EquipmenUTraininc�IFirc Eztinguishcr Must be Currenl <br /> I.isl Glcr.trical I lazards R Conlrols(GI=CI) <br /> I.isl l iazardous Malcrials in Usc <br /> lisl fbwet Tools <br /> I.isl I-Icavy l=gt�mienl{vehicle number) ��� C7 b � �Gly p O �� � — <br /> Lisl Personal Proleclrve Gqui n� nenl_ _. ��Ik)h-Vis �{ i r.ird lial liearinq Proleclion <br /> I 1_(:Imin Saw Chaps ❑ f_ye/Face ❑ Respira�o� ❑ <br /> Personnel On-Site <br /> Namc Assignmenl Namc Assignmenl <br /> S�J (�/.� � - -- -- <br /> ��?i ✓'�o�ti �C 0 <br /> ��u��------- -- (�, c. -- -- — -- -- — <br /> %P�' �'�i/.. � , (.. <br /> �', ? c i <br /> it,•.,,�,ac�vor, I - ) <br /> � , <br /> "i <br /> J <br />