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JOBSITE SAFETY WOi�KSHEET <br /> Route to Safety within 4 days <br /> � <br /> Date 3- ' -- p �— —--- Location � __,i—'_��I .�r��( <br /> �"------ ----- Clb <br /> Name ' 1—fL�(S� __ Job # Zv��' OC�ZY <br /> Start Time d �D� End Time <br /> _/S-3 0 <br /> Description of Work i ., S !-c,, I( ��w L�� �,✓2 �cz � � <br /> s-� .� � � � �t oc�� e <br /> �-f Se/'✓�'c� (va�.�: c � s/w <br /> If all abovc bold line is N/A, you do not nced lo comp�cic this fonn YES NIA <br /> Traffic Control Required—�Ilach TCP if modified — <br /> Excavation[nlry ovcr 3�/cl decp �� ❑ Nolify Dis�,atch <br /> Final Depfh y Widlh � <br /> � -- Lenglh� / <br /> �_) Shoriny ❑ Slopiny ❑ Trench�ox <br /> Confined Spnce f_nlry—�tlach ConMed Space Paperwo�k ❑ Nolify Oispalch � <br /> Unconlrolled Ener9y—Atlach Luckou(Form ' <br /> Ulililies Localed/ 10-foo�minimum ovahead deamnce from overhead power � <br /> _Cranes 8 Rig inc —Inspecled 13efore Use ,� <br /> Falls ovcr 4 fccl aic conlrollr.d � <br /> Conmmnicalion wilh emergency�,ponders provided <br /> ❑ Radio Dispa�ch Phone�J11 n CitY Phonc J-911 <br /> Firsl Aid EquipmenUTraininglFire Extinguishcr Must bc Current <br /> I.isl[Ieclrical liazartls&Conlwls(GI=CI) <br /> Lisl liazardous Atalcrials in Usc <br /> I.isl Power 1'ools <br /> Lisl I�Ieavy 6qui n� nenl(vel�icic ni_mil�cr) ��� � b � �jJj.� O �� � <br /> Lisl Personal Proleclive L=qu�menf _ I liqh-Vis � r�,�rd I lal liearin Pro�ec�ion <br /> _�_� Chain Sa�v Chaps ❑ [Y�/I'ace ❑ Respiralar ❑ <br /> _ Personnel On-Site <br /> Namc Assignmenl Name Assignmenl <br /> —� S�1 (',,�.J' � <br /> __l/yJ� fQr��. �G 0 <br /> �s� u, � <br /> 171�,��el.: � u L <br /> Revisecl 61110G <br />