314 42ND ST SW 2016-01-01 MF Import

�. �� _.: . .. _ r�: ,,,:� � ��'�'�' - - - � ..Ai i ��, ;,. . '�� �;�, ° ,,:�� _ ��. I,.r :s�a � �� EXCAVATION�TIi�NCHING SAFETY CH�CI'L'IST ` . ;;;,,, ��j Work order �`# '�1�' �'- �� ' . '�� . �atei s) of work: �r �r� �� S �- S . l,�.J --�— �, � � ' _— / ' ��'; ,ocation of work: _ � �„„ • e of'ob?..........................Yes�-`Lr� ❑ : a, s a"Competent Person", as defined ia WAC 296-155-650, m charg J . . ........................... .........................................Yes� N° ❑ �ias Dial-A-Dig been called?...••••••••••••�•••�"�"""""� Date &Tim�Dial-r�-Dig Done ;�ial-A-Dig number _—�-- 0 Are traffi:: c;�ntol devices in place? ........................................ ................................................Yes-� .. .................Yes � No� � tion on the toe e;a tiill, slope, or near a retaining wall?.........-•.••.••• Istr�r:'i`.�: :::.:, (i i ��s, coasult supervisor or engineer for recommendations. YeS�No ❑ If tre ;`".�?xcavation is less thui 4 feet deep are sides stable?............................................ (If not, then trench/escavation must be shored.) Y�S � No � i� . ..... R � f � �� If ttench is more than 4 fec[deep is shoring in use?.......................................... .... .. .....Yes ❑ NO ❑ ':.�"'" r ` �� ............................../...� .. .....:.........Yes� No ❑ Is shoring rated for depth of trench/excavation.. �................... . Is tabulated data for the shoring on the job site?.......................... .. � other material stored at lease 2 feet from the edge of fll�•••••••••••••�••�""'••••• YeS�No ❑ i Are spoil piles and '; trencl�/excavation? ' water removed from the bottom of the trencl�/excavation?.•�••••••�•••••••"""""'�'��Ye��No ❑ Is ❑ No � . ........Yes ❑ Is a ladder available for entrylexit from trznch/excavation?....................................: � � No �, Yes ❑ 1 ❑ N° �'� . , ..... .. ............Yes ❑ ................. � No � ........................................ .... ............... ........Yes ❑ Does it extend 3 feet above ton of trench?..•••••••••••••••"""�""'�� . . . . . . . . . . . . . . Is it secured at the top................... . . .. v.................... .. . . . . . .. Has it been inspected for defects/problems today. Is there a means of communication�vith rescuers in the event of an accident/problem?•�•••..::;: Ye �No ❑ • Are the open sides of the trench/excavation barricaded, or protected, to prevent falls••�"�' 1,es �- `. industrics,�vork over landfills, or other situations.) Is there is a possibility of hazazdons atmospheres m the trencl�/ezcavauon?•••�•�•••�•�••••""�' � (Such as from leaking gas mains, nearby � No ... " vatcon? ..............Yes ❑ No ❑ If yes, is a cali�StOd etr eval avail ble for workers in the trer}� If yes, is a me No Ar� all workers on site aware of fety requiremen for wor'�cer; �n trenches/excavations��3 S �/� L� /� N Date: Si;n�+r.�;re of Crew Leader: / r� �� ' s� ;'� i-F . . . �tFi�r�H3F'�'��;I�� I