WATER - CAPITOL PROJECTS

• Audit Title

• Document No.

• Client / Site

• Location
  Address

• Conducted on

  Date

• Prepared by

• SIGNITURE OF AUDITOR

  Sign

PPE

• SAFETY GLASSES

  Yes

  No

  N/A

• HARD HAT

  Yes

  No

  N/A

• GLOVES

  Yes

  No

  N/A

• TRAFFIC VESTS

  Yes

  No

  N/A

• HEARING PROTECTION

  Yes

  No

  N/A

• SAFETY BOOTS

  Yes

  No

  N/A

• OTHER

  Yes

  No

  N/A

JOB SITE

• UTILITIES LOCATED/GUARDED

  Yes

  No

  N/A

• HOUSEKEEPING/CLEAR PATHWAY

  Yes

  No

  N/A

• EXCAVATION/TRENCH GUARDED

  Yes

  No

  N/A

• OTHER

  Yes

  No

  N/A

CONFINED SPACE

• RETRIEVAL EQUIPMENT

  Yes

  No

  N/A

• ENTRY PERMIT

  Yes

  No

  N/A

• VENTILATION

  Yes

  No

  N/A

• TRI POD

  Yes

  No

  N/A

• GAS DETECTOR

  Yes

  No

  N/A

• CALIBRATED

TOOLS

• SAFE CONDITIONS EXIST

  Yes

  No

  N/A

• USED CORRECTLY

  Yes

  No

  N/A

• CORRECT FOR JOBTASK

  Yes

  No

  N/A

• OTHER

  Yes

  No

  N/A

EQUIPMENT

• BACK UP ALARMS FUNCTIONING

  Yes

  No

  N/A

• SPOTTER USED FOR BACKING

  Yes

  No

  N/A

• STROBES/WARNING LIGHTS

  Yes

  No

  N/A

• SEAT BELT USE

  Yes

  No

  N/A

• OTHER

  Yes

  No

  N/A

OTHER

• OTHER

  Yes

  No

  N/A

• COMMENTS

  Yes

  No

  N/A

• SIGNITURE OF AUDITOR

  Sign

• Select date

  Date