Statoil Ground Disturbance Permit

• Prepared by

• Phone Number

• Date/Time Permit Initiated

  Date

• Date/Time Permit Expires

  Date
• Location Name:
  Address

• Century Supervisor

• Phone Number:

• State Oil Representative

• Phone Number:

• Emergency Contact Phone Number:

• Alternate Phone Number

One-Call Locate

• Requested by

• Phone Number:

• When was One-Call notified

  Date

• Locate Ticket Number

Utility Owners

Owner

• Utility Owner

• Type of utility

  Select Communications Electrical Potable Water Non-Potable Water Sewer Pipeline - Gas Pipeline - Crude Oil Other

  • Communications
  • Electrical
  • Potable Water
  • Non-Potable Water
  • Sewer
  • Pipeline - Gas
  • Pipeline - Crude Oil
  • Other

• Type of utility

• Name of Locator

• Contact number

• Description of work to be performed

Status Report: NOTE: for any item answered "NO" a Statoil Manager must Approve before work proceeds

• 1. One-Call has been notified and contacts have been made to determine the existence and location of ALL underground facilities in the vicinity of the work area.

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• This is not an allowable answer

• 2. Available records have been referenced and a plot plan indicating the location of all underground facilities has been provided and is available for reference at the work site.

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• 2a. Have Area Operations Personnel been consulted for obtaining or discussing: Plot Plans<br>

  Yes

  No

  N/A

• Directives given

• Statoil Manager contacted

• This is not an allowable answer

• 2a. Have Area Operations Personnel been consulted for obtaining or discussing: Pipeline or Facilities Maps

  Yes

  No

  N/A

• Directives given

• Statoil Manager contacted

• This is not an allowable answer

• 2a. Have Area Operations Personnel been consulted for obtaining or discussing: Lease Maps (as available)

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• 2b. Has the work area been checked for facilities/pipelines, or utility markers

  Yes

  No

  N/A

• Directives given

• Statoil Manager contacted

• This is not an allowable answer

• 2c. Has the company on the markers been contacted?

  Yes

  No

  N/A

• Directives given

• Statoil Manager contacted

• This is not an allowable answer

• 2d. Are there any signs of ground disturbance within the proposed work area, including the search zone?

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• 2e. Have attempts been made to communicate with the landowner and/or tenant to establish verification of buried utilities?

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• 3. All approvals, notifications and agreements have been obtained

  Yes

  No

  N/A

• Directives given

• Statoil Manager contacted

• This is not an allowable answer

• 4. A pre-job safety meeting, including Safe Job Analysis has been conducted by the Competent Person.

  Yes

  No

  N/A

• Directives given

• Statoil Manager contacted

• This is not an allowable answer

• 5. The Emergency Response Plan has been reviewed and is available at the work site. When applicable, the nearest pipeline isolation valves identified and incorporated into the plan.

  Yes

  No

  N/A

• Directives given

• Statoil Manager contacted

• This is not an allowable answer

• 6. The proposed ground disturbance area(s) have been identified and all underground facilities in the dig zone and search zone have been identified and incorporated into the plan.

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• This is not an allowable answer

• 7. Approved techniques for exposing underground facilities within 2 feet of ground disturbance have been (or will be) used to verify the location of all known underground facilities.

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• 8. Other Safe Work Permits, as applicable, have been issued (Confined Space, Hot Work, LOTO, etc.)

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• 9. Precautions have been taken to prevent contact with overhead power lines.

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• 10. Appropriate internal communications (team leader, field tech, land owner, etc.) have taken place.

  Yes

  No

  N/A

• Directives given

• Statoil Manager contacted

• This is not an allowable answer

• 11. New non-metallic underground facilities are being installed with line locating capability.

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• 12. All personnel involved with the excavation have received the appropriate training.

  Yes

  No

  N/A

• Directives given

• Statoil Manager contacted

• This is not an allowable answer

• 13. Risk has been assessed, and provisions have been/will be made to address unattended open excavations to insure the safety of the general public, livestock and wildlife until the site is remediated.

  Yes

  No

  N/A

• Statoil Manager contacted

• Directives given

• This is not an allowable answer

• Additional comments, Instructions or requirements:

• Legend

  Media

• Plot Plan Drawing

  Drawing

• Plot Plan Image

  Media

• Drawn By:

• Once this form has been fully completed it must be authorized by by the designated Statoil Manager or Supervisor at the beginning of the aforementioned work day.

  Sign

• Check if Statoil Manager or Supervisor is not available

• Statoil Manager/Supervisor Contacted by phone:

• Directives given:

• Date and time of phone call

  Date

• The provisions of this permit have been discussed with the following people:
  (include everyone that is currently working on said ground disturbance)

Person

• Add signature

  Sign