Title Page
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Conducted on
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Site
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Prepared by
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Contractor Performing Work
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CXP Segment Information
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Page #'s of CXP being worked at this excavation site
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Location of Work Performed
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Do you have all CXP prints associated with the excavation area and are they at a suitable scale to be understood? (Approved design drawing for construction, Permitting CXP and GIS data )
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Contact leadership and do not proceed with any excavation of the area!
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What known utilities are in the vicinity of the excavation area?
- Blue: Potable Water
- Green: Sewer and Drain Lines
- Purple: Irrigation and Slurry Lines, Reclaimed Water
- Red: Electrical Power Lines, Cables, Conduit and Lighting Cables
- Yellow: Gas, Oil, Steam, Petroleum or Gaseous Materials
- Orange: Communications, Alarm or Signal Lines, Cables or Conduit
- Pink: Temporary Survey Markings
- White: Proposed Excavation
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Provide 811 ticket number
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Have all known utilites been located at the excavation site?
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Contact leadership and do not proceed with any excavation of the area!
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Provide photos of all locates within the excavation site.
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Have you identified all areas that need to be pot-holed?
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What is the current state of the proposed work area?
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Is the area traffic sensitive?
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Do you have all of the required signage, cones, flaggers or other equipment for proper traffic mitigation?
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Contact leadership and do not proceed with any excavation of the area!
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Were all yard signs and door hangers placed at least 48 hrs prior to excavation?
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Will the required work cause you to go beyond normal working hours of 8am-5pm
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Are there any access restrictions?
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Are there any SED's (Special Engineering Difficulties)?
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Have all hazards been identified and risk assessed? ( Photo of Risk Assessment)
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Photo of Risk Assessment required
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Review risks and implement control measures required - can the works safely continue?
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Consult with your manager and don't proceed with the works!
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Photo of Risk assessment.
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Are there residents to inform of the work?
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Have they been informed?
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Are there any Specific requirements from the Primary Contractor?
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Please specify?
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Name and Signature of person completing form
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Management Approval
