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(47T <br />JOBSITE SAFETY WORKSHEET <br />Location 53v2- /ro�`��,L_ <br />Date _-g --_pi2 <br />—7 _ <br />Lead G /� <br />Description of Work/Safely Corninenls iNf� (l r�4�, J e2 <br />rt,2 C.� (_ ---- o <br />11 all above bold line is NA, you do not need to complete this form YES NIA <br />Traffic Control Re uired—Allach TCP of modified <br />Excavation Entry over 3 feel deep l <br />// <br />Final Depth _ WidthLength____ <br />/ <br />❑ Finn Form ❑ Sloping ❑ Trench Box ❑ Build a Box <br />Confined Spice Ent —Attach Confined Space Pa e(work <br />Uncontrolled Ener —Allach Lockout <br />Not Work —Describe <br />Overheadpower—Minimurn 10' clearance <br />/ <br />Overhead lillin —Cranes & Rigging Inspected Before Use <br />Falls over 4 feel—Conirolled by: <br />First Aid E ui mentiTrainin (Fire Extinguisher Must be Current <br />Utilities Located: ❑ Water (blue) ❑ Power(red) ❑ Gas(yellow) ❑ Communication (orange) ❑ other <br />Communication with emergent sponders provided <br />❑ Radio Dispatch Phone 91 I ❑Ci4Y Phone 9 911_ <br />Electrical Ilazaids B Controls GFCI <br />Ilazardous Materials in Use <br />Power Tools <br />flea Equipment vehicle number Q� <br />Personal Protective Equipment L �� <br />Pre -Job Sa ety Meeting <br />Name <br />Assignment <br />Name <br />Assignment <br />,0- (, <br />nes+sed 9 01 09 <br />9// <br />