Title Page
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Competent Person
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Date / Time
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Conducted by
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Location
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Weather
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1.0 Workplace
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1.1-Code 753 (Mark Outs)
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1.2-Inspector
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1.3-Competent Person
2.0 Administrative
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2.1-Documentation of Job Briefing
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2.2-HASP on-site & current
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2.3-Air monitor in use, calibrated, & current
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2.4-Current permits posted & visible
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2.5-Complete Job Package on-site
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2.6-First Aid Kit/Blood Bourne Pathogen Kit on-site & current
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2.7-Spill Kit on-site
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2.8-Fire extinguisher visible, current, & immediately available
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2.9-Current RWLB matrix posted
3.0 Work Area Protection
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3.1-Flagger present
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3.2-Barricades/Cones/Stanchions complete & in compliance
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3.3-MUTCD signs in use where required
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3.4-Arrow board operating & in use when applicable
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3.5-Pedestrians provided with a safe & clear path of travel
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3.6-Plates Pinned, ramped, flush, skid resistant, & in complete compliance
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3.7-Slings & chains in good condition
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3.8-Rubber Electrical Gloves (KV) dated with expiration date
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3.9-Proper PPE in use when required
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3.10-Vehicle's engine turned off (Idling regulations)
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3.11-Wheels chocked when truck on standby (driver not in cab)
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3.12-All tools in good condition
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3.13-Adequate set-up
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3.14-Housekeeping in place on-site & in trucks to prevent slips, trips, and falls
4.0 Excavation
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4.1-Spoils & equipment 2' away from excavation
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4.2-Gas monitoring where required
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4.3-Ladders used at 4' depth or greater and extending 3' above landing
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4.4-Ladders in place every 25' of lateral travel
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4.5-Shoring/sheeting at 4'6" or greater or when required
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4.6-Daily excavation inspection conducted
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Notes/Other:
5.0 Gas/Fusion Equipment
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3.1-Contact Pyrometer
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3.2-Manual Fusion machine
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3.3-Facer
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3.4 Heating Iron
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3.5 Hydraulic Fusion Machine
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3.6-Electrofusion Machine
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3.7-Airline Respirator complete including inhalation valve, exhalation valve, hose assembly, speaking diaphragm, gaskets, connections, regulator, alarm, and hoses
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3.8-Harness & Line
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3.9-Escape Kit current (Mask & O2)
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3.10-GMI Current
Sign off
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On-site Representative
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Auditor's signature