Vali Industries Inc.

• Competent Person

• Location
  Address

• Date / Time

  Date

• Conducted by

• 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-Air monitor in use, calibrated, & current

  Yes

  No

  N/A

• 2.4-Current permits posted & visible

  Yes

  No

  N/A

• 2.5-Complete Job Package on-site

  Yes

  No

  N/A

• 2.6-First Aid Kit/Bloodbourne Pathogen Kit on-site & current

  Yes

  No

  N/A

• 2.7-Spill Kit on-site

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.9-Current RWLB matrix posted

  Yes

  No

  N/A

3.0 Work Area Protection /PPE

• 3.1-Flagger present

  Yes

  No

  N/A

• 3.2-Barricades/Cones/Stanchions complete & in compliance

  Yes

  No

  N/A

• 3.3-MUTCD signs in use where required

  Yes

  No

  N/A

• 3.4-Arrow board operating & in use when applicable

  Yes

  No

  N/A

• 3.5-Pedestrians provided with a safe & clear path of travel

  Yes

  No

  N/A

• 3.6-Plates Pinned, ramped, flush, skid resistant, & in complete compliance

  Yes

  No

  N/A

• 3.7-Slings & chains in good condition

  Yes

  No

  N/A

• 3.8-Rubber Electrical Gloves (KV) dated with expiration date

  Yes

  No

  N/A

• 3.9-Proper PPE in use when required

  Yes

  No

  N/A

• 3.10-Vehicle's engine turned off (Idling regulations)

  Yes

  No

  N/A

• 3.11-Wheels chocked when truck on standby (driver not in cab)

  Yes

  No

  N/A

• 3.12-All tools in good condition

  Yes

  No

  N/A

• 3.13-Adequate set-up

  Yes

  No

  N/A

• 3.14-Housekeeping in place on-site & in trucks to prevent slips, trips, and falls

  Yes

  No

  N/A

4.0 Excavation

• 4.1-Spoils & equipment 2' away from excavation

  Yes

  No

  N/A

• 4.2-Gas monitoring where required

  Yes

  No

  N/A

• 4.3-Ladders used at 4' depth or greater and extending 3' above landing

  Yes

  No

  N/A

• 4.4-Ladders in place every 25' of lateral travel

  Yes

  No

  N/A

• 4.5-Shoring/sheeting at 4'6" or greater or when required

  Yes

  No

  N/A

• 4.6-Daily excavation inspection conducted

  Yes

  No

  N/A

• Notes/Other:

Sign off

• On-site Representative

• Auditor's signature