Tri-Messine Construction Co. , Inc.

• Competent Person

• Conducted on

  Date

• Prepared by

• Location
  Address

• Opening Ticket Number

• Permit Number

• Weather

1.0- Workplace

• 1.1.-Code 753 (Mark Outs)

  Yes

  No

  N/A

• 1.2- Inspector

  Yes

  No

  N/A

• 1.3- Competent Person

  Yes

  No

  N/A

2.0- Administrative

• 2.1- Documentation of Job Briefing

  Yes

  No

  N/A

• 2.2- HASP on-site & Current

  Yes

  No

  N/A

• 2.3- HASP Acknowledgement form on-site & signed

  Yes

  No

  N/A

• 2.4- Certificates & Training Cards

  Yes

  No

  N/A

• 2.5- Safety Data Sheets, SDS, on-site

  Yes

  No

  N/A

• 2.6- Current RWLB Matrix Posted

  Yes

  No

  N/A

• 2.7- Complete job package on-site

  Yes

  No

  N/A

• 2.8- Noise Mitigation Plan posted

  Yes

  No

  N/A

• 2.9- First Aid Kit/Blood Bourne Pathogen Kit on-site & current

  Yes

  No

  N/A

• 2.10- Spill Kit on-site

  Yes

  No

  N/A

• 2.11- Fire extinguisher visible, current, & immediately available

  Yes

  No

  N/A

3.0- Work Area Protection

• 3.1- Flagger posted with advanced warning signs

  Yes

  No

  N/A

• 3.2- Adequate set-up

  Yes

  No

  N/A

• 3.3- Cones and double topers connected where required

  Yes

  No

  N/A

• 3.4- MUTCD set-up signs in use when required

  Yes

  No

  N/A

• 3.5- Arrow board operating properly & in use if applicable

  Yes

  No

  N/A

• 3.6-Housekeeping

  Yes

  No

  N/A

• 3.7- Pedestrians provided with safe & clear travel

  Yes

  No

  N/A

• 3.8- Plates; pinned, ramped, flush, & skid proof where required

  Yes

  No

  N/A

• 3.09-Rubber electrical gloves dated within the expiration

  Yes

  No

  N/A

• 3.10- Proper PPE in use when required

  Yes

  No

  N/A

• 3.11- Vehicle's engines turned off (idling regulations)

  Yes

  No

  N/A

• 3.12- Wheel Chocks in use when truck is in standby

  Yes

  No

  N/A

• 3.13- Hydrants & bus stops clear

  Yes

  No

  N/A

• 3.14- All tools in good shape

  Yes

  No

  N/A

4.0- Vehicle Inspection

• 4.1- Truck Operator

• 4.2- License Plate #

• 4.3- Body up indicator Light & Buzzer

  Yes

  No

  N/A

• 4.4- Truck Registration

  Yes

  No

  N/A

• 4.5- Truck Insurance

  Yes

  No

  N/A

• 4.6- Truck overweight permit

  Yes

  No

  N/A

Sign off

• On-site Representative

• Auditor's Signature