Critical Lift Plan

Elkhorn Construction, Inc Safety Manual Title: Critical Lift Plan Effective Date: 12-15-2008

Critical Lift Plan

Date: ______

Location of Lift: ______

Description of Object To Be Raised: ______

______

Lifting Equipment Make & Model: ______

Lifting Equipment Rated Capacity: ______tons

Load Total Weight of Lift: ______pounds or ______tons Weight Of Rigging: ______pounds How Was Weight of Object Obtained?______If lift is an existing item, weight calculations will include modifications, liquid remaining, insulation, sludge, scale, sediment, etc.

Set Up Boom Angle: ______degrees Distance From Pin:______feet Crane Capacity at Set Up Configuration: ______pounds or ______tons Load Including Rigging is What Percent of Rated Crane Capacity ______%

Equipment and Lift Relationship Maximum Operating Radius ______feet Planned Operating Radius ______feet Allowable Load (from load chart) ______tons or ______pounds Ratio of Lift to Allowable Load ______percent Clearance Between Boom and Load ______feet ______inches Clearance To Existing Facilities ______feet Clearance To Energized Power Lines ______feet

Ground Stability Surface Type ______bare ground ______asphalt ______concrete Surface Bearing Capacity ______tons per square foot Type of Support Used ______mats ______cribbing Mats will be used on all surfaces; additional cribbing may be required Size and Number of Supports ______Do Underground Installations Need Special Treatment ______yes ______no

Document No: 2B-00xx Revision 1 Page 1 of 2 Elkhorn Construction, Inc Safety Manual Title: Critical Lift Plan Effective Date: 12-15-2008

Weather Lift Will Not Proceed if Wind Exceeds ______mph Precipitation Type ______rain ______snow ______none Cloud Type overcast ______clear ______Lift Conducted ______during daylight ______with artificial light

Lift Area Restriction Area Barricaded ______yes ______no Equipment swing Radius Barricaded ______yes ______no Warning Signs Required ______yes ______no Unnecessary Personnel Removed From Area ______yes ______no Energized Lines Isolated ______yes ______no

Communication Operator View is Unobstructed (pick to set) ______yes ______no Communication Used ______hand signals ______radio ______other Explain Other ______

Pre-lift Safety Meeting Type of Critical Lift ______Load Exceeds 75% of Load Chart Capacity For Lifting Equipment ______Two or More Cranes/Booms Required for Lift ______Specialized Hoisting Rigging Equipment Used ______Load Suspended or Moved Over Loaded Lines ______Other (specify) ______

Items Discussed ______

______

Crane Operator ______Crane Rigger ______Crane Oiler ______Signal Person ______Crane Inspected By ______Rigging Inspected By ______Client Representative ______Designated Lift Leader ______

Document No: 2B-00xx Revision 1 Page 2 of 2