Excavation and Trenching Permit - Example 1

Form 000.653.F0206 Excavation and Trenching Permit – Example 1

EXCAVATION AND TRENCHING SAFETY CHECKLIST (Prework and Daily Inspection) PREWORK

Job/Task ID: Excavation Permit No.: Verified By Date

Excavation permit is completed, dated, all required signatures Supervisor: obtained, all attachments/scans/etc. are complete as required. (Supervisor and Competent Person) Competent Person: Competent Person(s) has been designated/assigned; designation Supervisor: form is complete/current (within 1 year). (Supervisor) Initial (preexcavation) call to Date: “U DIG” has been made. Supervisor: Time: (Supervisor) Walkdown of proposed excavation performed. (Supervisor and Competent Person) Walkdown to ensure: . Ground markings identifying underground obstructions Supervisor: are present and applied in accordance with 000.653.3311. . Evaluation of the work area for potential hazards that have not been addressed by scanning existing drawing Competent research efforts and/or other pre-task planning activities. Person: Excavation work is released to begin. Supervisor: (Supervisor)

EXCAVATION AND TRENCHING DAILY INSPECTION LOG The applicable items listed on page 3 of the Excavation and Trenching Permit were verified. Deficiencies observed are noted with the corresponding action that was taken to eliminate the hazard. Condition Inspected By D Time Comments/Deficiencies Noted Corrective Action Taken (Competent Accept Not Accept Person)

EXCAVATION/TRENCH SAFETY CHECKLIST DAILY INSPECTION Inspection of the excavation/trench, including adjacent areas and protective systems, are conducted daily by a Competent Person. The Competent Person inspects for evidence of situations that could result in possible cave-ins, indications of protective system failures, indications of a hazardous atmosphere, and other hazardous conditions. Inspections are conducted after every rainstorm and any other potential hazard-increasing occurrence. Sloping and shoring comply with Practice 000.653.3311 unless alternative methods are formally agreed to and documented on the permit/JSA. The following items (as applicable) are verified and the results documented on page 2 of the Excavation and Trenching Permit:

. The excavation permit is valid, signed, and dated. Excavation began within 60 days of facility/system owner’s signature or by the permit expiration date.

. Scan document is valid.

. Employees have received a daily briefing on the composite scan drawing, the excavation/trench’s special requirements, and excavation hazards.

. The area surrounding the excavation/trench has been properly protected and barricaded.

. Ensure “U DIG” has been notified 10 days before excavation and every 10 days during excavation (as/if applicable).

. Utilities have been located, protected, and marked (refer to composite scan drawing).

. The excavation (if 5 feet [1.5 meters] or deeper) is properly sloped or shored.

. Foundations, structures, and appurtenances, for example, are supported or underpinned.

. Protective systems being used comply with the manufacturer’s instructions or engineering designs.

. Sloping or protective systems have been checked for evidence of failure (such as soil distress, structural member damage, or soil fissures).

. A means of egress (such as a stairway, ladder, or ramp) is provided within 25 feet (7.6 meters) of each person in the excavation/trench.

. Walkways or bridges with standard handrails are provided where personnel are required to cross the excavation/trench.

. Excavated materials have been placed at least 2 feet (0.6 meter) away from the edge of the excavation/trench.

. A determination has been made whether or not to classify the excavation/trench as a confined space.

Note: If the excavation/trench is classified as a confined space, ensure monitoring (as required on the confined space entry permit, if any) is performed before employees are allowed to enter.

. The excavation/trench is safe for employees to enter.

. Pre-task planning documents have been updated, as required, to reflect changes in work scope, site conditions, or hazard change. Planning documents have been discussed with, and signed by, affected employees.

. Corrective measures have been taken to eliminate existing or predictable hazards.

Permit No. EXCAVATION PERMIT

1. Work Package No. 2. Task/Project No. 3. Location of Excavation

4. Originated By Date 5. Change Notice

6. Drawings Required (identification No.) 7. Other Affected Drawings or Documents (if any)

8. Description of Work (attach composite drawing of excavation location and all known interferences)

9. Special Instructions or Comments

Preexcavation scan(s) required? No Yes (specify) 10. Excavation Requirements Planning Checklist (check appropriate blocks to determine supplemental approvals)

Will the excavation be:

Yes No Within 25 feet (7.6 meters) of the center line of a railroad track? Within 5 feet (1.5 meters) of an energized utility? Performed in areas other than existing utilities, buildings, waste sites, and those required to remove existing surplus facilities? (If yes, “site” planning approval required in Block 15.) Performed to expose underground utilities/structures? 11. List Facilities, Services, Structures, and Utilities Affected by Excavation

Approvals 12. Construction Supervision Date

13. Project/Construction Engineer Date

14. Project HSE Date

15. Site Planning (if applicable) Date

16. Facility/System Owner/Cognizant Engineer (last signature) Date

INSTRUCTIONS FOR COMPLETING THE EXCAVATION PERMIT

Permit No. Obtain from Project HSE.

Block 1 Enter work package number.

Block 2 Enter appropriate source of funds or project number, if known.

Block 3 Enter brief location where excavation work is to be performed.

Block 4 Originator name and date.

Block 5 If associated with a change notice (such as DCN, ECN, FMP, etc.), enter the number.

Block 6 List drawings that describe the work to be performed.

Block 7 List other drawings or documents affected by the excavation work, if any.

Block 8 Describe the purpose of the excavation work. Attach a composite drawing identifying each of the areas to be excavated and all known interferences.

Block 9 Enter special instructions/comments or requirements relating to the excavation, such as safety requirements or additional required permits. Identify required pre-excavation scanning, if any, and specify.

Block 10 Check appropriate blocks to determine supplemental approvals.

Block 11 List utilities, services, and facilities that either will, or may be, affected by the excavation.

Blocks 12-15 Obtain approvals from designated organizations.

Note: This form is referenced in Practices 000.653.1003 and 000.653.3311.