Attachment R - Excavation Permit.pdf

VA Long Beach Healthcare System ES Form 600-138G-2 EP Revised – N/A

This permit is required per VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements Subtopic 1.18, to be completed prior to digging, drilling or trenching operations and prior to entering excavations and/or trenches. Contractors/VHA employees must obtain written permit from Safety/Engineering personnel for all excavations 2 feet in depth or greater. Permits and daily safety checklist must be present and posted at all excavation worksites. Per Federal Acquisition Regulation (FAR) 32.601, Government expense of correcting defects, reinspection costs and damage costs related to defaults in performance will result in a contractor’s debt and will be due from the contractor under the terms and conditions of the contract. Page 1 of 4

EXCAVATION PERMIT

Section I. Complete by Competent Person prior to digging/drilling and prior to proceeding with entering the excavation

1. Project No.

2. Project title

3. Date:

4. Originated By

5. Phone #

6. Prime Contractor Performing Work

7. Phone #

8. Specific Location:

9. Estimated Dates and Times of Excavation.

Start Date: Start Time: End Date: End Time:

10. Reason for Excavation:

11. Contractors “Competent Person” Print/Sign Below. *

Printed Name: Signature: Date:

*CP must have received 30hr OSHA Construction training as well as formal training in Excavation safety.

12. Excavation Requirements Planning Checklist (check appropriate blocks to determine supplemental approvals)

Yes No

Has review of site drawings been executed and proximity of utilities been determined? (Utility locations must have proper ground markings once they are identified). If so, which qualified utility finding service was used?

As-built survey GPRS Pot Holding Other________________________

Are soil samples required to determine soil contamination?

Has coordination with COR/PM been established?

Is soil or concrete removal to an offsite location necessary?

Has the proposed worksite and workplan been evaluated and deemed eligible per historic preservation standards and guidelines? (State Historic Preservation Office (SHPO), Native American Graves Protection and Repatriation Act (NAGPRA), Etc.)

13. List Facilities, Services, Structures, and Utilities Affected by the Excavation.

14. Map of planned excavation area and any relevant site drawings included.

Approvals

15. Contractor Construction Supervision Signature: Date:

16. Project Engineer/COR Signature: Date:

17. VA Safety Signature: Date:

Note: Return all sections of this permit to Project Engineer and copy to VA Safety Office at completion of job.

This permit is required per VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements Subtopic 1.18, to be completed prior to digging, drilling or trenching operations and prior to entering excavations and/or trenches. Contractors/VHA employees must obtain written permit from Safety/Engineering personnel for all excavations 2 feet in depth or greater. Permits and daily safety checklist must be present and posted at all excavation worksites. Per Federal Acquisition Regulation (FAR) 32.601, Government expense of correcting defects, reinspection costs and damage costs related to defaults in performance will result in a contractor’s debt and will be due from the contractor under the terms and conditions of the contract. Page 2 of 4

EXCAVATION PERMIT

Section II Part A. Completed by the Competent Person prior to personnel entering an excavation greater than 5 feet in depth

Name of Competent Person: Date:

M E

T

N O

T M

E T

N /A

REQUIREMENT

1. Are the estimated locations of utility installations, such as sewer, telephone, fuel, electric, water lines, or any other underground installations that reasonably may be expected to be encountered during excavation work determined prior to opening an excavation? [OSHA 29 CFR 1926.651(b)(1)]

2. Are utility companies contacted within established or customary local response times, advised of the proposed work, and asked to establish the location of utility underground installations up to their own meters prior to the start of actual excavation? [OSHA 29 CFR 1926.651(b)(2)]

3. On VHA property, is the proposed dig site being marked, “as built” drawings reviewed, and visual indicators (manholes, valves, meters, permanent markers, etc.) of the utilities being utilized to establish the location of utility underground installations by in-house VHA personnel or a contracted private locator service? [OSHA 29 CFR 1926.651(b)(2)]

4. On VHA property, are locations of utility underground installations being marked and maintained by use of stakes, paint, flags, or other clearly identifiable materials to show the field location of underground facilities, in accordance with the current color code standard of the American Public Works Association (APWA) Uniform Color Code.? [OSHA 29 CFR 1926.651(b)(2)]

5. If utility companies or the VHA cannot locate underground utility installations or cannot establish the exact location of these installations, are excavation contractors proceeding with caution and using detection equipment or other acceptable means to locate utility installations (careful hand digging, pot-holing and vacuum excavation, hand tools that use air or water under pressure, exploratory bar, or other)? [OSHA 29 CFR 1926.651(b)(2)]

6. When excavation operations approach the estimated location (within 2 feet) of underground installations, are the exact location of the installations determined by safe and acceptable means (careful hand digging, pot-holing and vacuum excavation, hand tools that use air or water under pressure, exploratory bar, or other)? [OSHA 29 CFR 1926.651(b)(3)]

7. While the excavation is open, are underground installations protected, supported or removed (Lockout/Tagout, supports built, etc…) as necessary to safeguard employees? [OSHA 29 CFR 1926.651(b)(4)]

8. Are Activity Hazard Analyses and excavation permits being completed prior to opening excavations? (FAR 52.236-13, Accident Prevention; VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements, Subtopic 1.5 & 1.18)

9. Where workers enter an excavation greater than 5 feet in depth, are soils being classified using a pocket penetrometer in accordance with OSHA classification system (Solid Rock, Type A, Type B, or Type C)? [OSHA Directive CPL 02-00-87; VHA Directive 2011-036, Subpar. 4(l)(7)] Note: If using an excavation protective system of sloping or benching, then the soil classification cannot be Solid Rock or Type A. Thus, the angle of repose cannot be steeper than 1 to 1 (45 degrees) (OSHA 29 CFR 1926.652 & associated Appendix A; VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements, Subtopic 1.18, Par. C)? Soil Type:________________

10. Where workers enter an excavation greater than 5 feet in depth, are protective systems being designed in accordance with 29 CFR 1926, Subpart P, Appendices B to F or designed by Professional Engineer [OSHA 29 CFR 1926.652(a)] Note: excavations in excess of 20 feet in depth must be designed by PE and sloping or benching systems cannot have an angle of repose steeper than 1 to 1 (45 degrees) as provided above.

Competent Person Signature:

This permit is required per VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements Subtopic 1.18, to be completed prior to digging, drilling or trenching operations and prior to entering excavations and/or trenches. Contractors/VHA employees must obtain written permit from Safety/Engineering personnel for all excavations 2 feet in depth or greater. Permits and daily safety checklist must be present and posted at all excavation worksites. Per Federal Acquisition Regulation (FAR) 32.601, Government expense of correcting defects, reinspection costs and damage costs related to defaults in performance will result in a contractor’s debt and will be due from the contractor under the terms and conditions of the contract. Page 3 of 4

EXCAVATION PERMIT

Section II Part B. Completed by the Competent Person prior to personnel entering an excavation greater than 5 feet in depth

EXCAVATION/TRENCH SAFETY CHECKLIST DAILY INSPECTION

Inspection of the excavation/trench, including adjacent areas and protective systems, are conducted daily (at a minimum) by a Competent Person. The Competent Person inspects for evidence of situations that could result in possible cave-ins, indications of protective system failures, indications of a hazardous atmosphere, and other hazardous conditions.

Inspections are conducted after every rainstorm and any other potential hazard-increasing occurrence.

Sloping and benching comply with OSHA 1926.651 and 1926 Subpart P App B.

The following items (as applicable) are verified and the results documented in the Excavation Permit Section II Part C:

The excavation permit is valid, signed, and dated. Excavation began within 60 days of facility/system owner’s signature or by the permit expiration date.

Scan document is valid.

All crew members have received a daily briefing on the work to be accomplished, the excavation/trench’s special requirements, and excavation hazards.

The area surrounding the excavation/trench has been properly protected and barricaded.

Ensure VHA and applicable utility company has been notified 10 days before excavation and every 10 days during excavation (as/if applicable).

Utilities have been located, protected, and marked per APWA Uniform Color Code.

The excavation (if 5 feet [1.5 meters] or deeper) is properly sloped or shored.

Foundations, structures, and appurtenances, for example, are supported or underpinned.

Protective systems being used comply with the manufacturer’s instructions or engineering designs.

Sloping or protective systems have been checked for evidence of failure (such as soil distress, structural member damage, or soil fissures).

A means of egress (such as a stairway, ladder, or ramp) is provided within 25 feet (7.6 meters) of each person in the excavation/trench.

Walkways or bridges with standard handrails are provided where personnel are required to cross the excavation/trench.

Spoil piles have been placed at least 2 feet (0.6 meter) away from the edge of the excavation/trench and safe access provided within 25 feet of the workers.

A determination has been made whether or not to classify the excavation/trench as a confined space.

Note: If the excavation/trench is classified as a confined space, ensure monitoring, as required on the confined space entry permit (VALB Engineering SOP 300.4-Safety, Confined Space Entry), is performed before employees are allowed to enter.

The excavation/trench is safe for employees to enter.

Pre-task planning documents have been updated, as required, to reflect changes in work scope, site conditions, or hazard change. Planning documents have been discussed with, and signed by, affected employees.

Corrective measures have been taken to eliminate existing or predictable hazards.

This permit is required per VA Master Specs, Div. 01, Section 01 35 26 Safety Requirements Subtopic 1.18, to be completed prior to digging, drilling or trenching operations and prior to entering excavations and/or trenches. Contractors/VHA employees must obtain written permit from Safety/Engineering personnel for all excavations 2 feet in depth or greater. Permits and daily safety checklist must be present and posted at all excavation worksites. Per Federal Acquisition Regulation (FAR) 32.601, Government expense of correcting defects, reinspection costs and damage costs related to defaults in performance will result in a contractor’s debt and will be due from the contractor under the terms and conditions of the contract Page 4 of 4.

EXCAVATION PERMIT

Section II Part C. Completed by the Competent Person prior to personnel entering an excavation greater than 5 feet in depth.

EXCAVATION AND TRENCHING DAILY INSPECTION LOG

The applicable items listed on Section II Part B of this Excavation Permit were verified.

Deficiencies observed are noted with the corresponding action that was taken to eliminate the hazard.

Date Time Condition

Comments/Deficiencies Noted Corrective Action Taken Inspected By

(Competent Person) Accept Not Accept

Note: Make copies of this page as needed.