ESC_Minor_Utility_Permit,_Health_and_Safety_Qualification_Questionaire,_and_Example_Health_and_Safety_Plan_outline.pdf

ATTACHMENTS

Washington Suburban Sanitary Commission – Erosion and Sediment Control Permit for Minor Utility Construction in Prince George’s and Montgomery Counties

WSSC Water Contractor Health and Safety Qualification Questionnaire

Attachment 1 – Example Health & Safety Plan Outline

WASHINGTON SUBURBAN SANITARY COMMISSION

EROSION AND SEDIMENT CONTROL PERMIT

FOR MINOR UTILITY CONSTRUCTION

IN PRINCE GEORGE’S AND MONTGOMERY COUNTIES

PERMIT NO. :__________________________

EXPIRATION DATE: ___________________________

In accordance with provisions set forth in the Md. Public Utilities Code Ann. §§ 17-403 and 17-406;

Md. Environment Code Ann. § 4-105; and the Utility Erosion and Sediment Control Regulations adopted by the Washington Suburban Sanitary Commission, permission is hereby given to to perform Minor utility construction(as defined by the Washington Suburban Sanitary Commission’s Utility Erosion and Sediment Control Regulations).

Contract Number (if applicable) ____________________________________________________________

CONDITIONS

1. All work done under this Permit shall comply with the below written conditions, the WSSC Utility

Erosion and Sediment Control Regulations, the “1994 Maryland Standards and Specifications for Soil Erosion and Sediment Control,” and any instructions issued by the Washington Suburban Sanitary Commission Environmental Group.

2. All responsible field personnel involved in construction of the project covered by this Permit shall have a Certificate of Attendance at a Maryland Department of the Environment approved training program for control of sediment and erosion.

3. A copy of this approved Minor Permit must be maintained on all applicable job sites.

4. Provide written notification of “emergency work” locations no later that 48 hours after construction has begun at WSSC fax 301/206-8057.

5. The holder of this Permit shall give at least 48 hours advance notice to the WSSC at 301/206-8077 before construction under this Permit is undertaken, and shall submit certification of completion of work for each project under this Permit to the WSSC. Any qualifying project found to be in progress for which the WSSC Environmental Group has not received advance notice will be considered non- Permitted, and subject to immediate citation action.

6. The holder of this Permit shall supply the WSSC with weekly written notification of work site locations at the WSSC Fax 301/206-8057.

7. The holder of this Permit shall supply the WSSC with a set of construction drawings for each project in excess of 1000 linear feet at least one week prior to construction, and weekly written notification of work site locations at WSSC fax 301/206-8057.

8. When any construction activities by the Permittee or his/her agent are in 100 year flood plains, streams or wetlands, supply WSSC with a copy of the designated Maryland State authority Permit or exemption letter at fax 301/206-8057, prior to the commencement of work.

9. The site, work, and materials under this Permit shall be available at all times for inspection by officials of the WSSC.

10. Deviations from the Procedures or Conditions set forth in this Permit require prior approval of the

WSSC.

11. This Permit is subject to suspension by the WSSC whenever determination is made and after notice is given that the Permittee is in violation of the WSSC Utility Erosion and Sediment Control Regulations or the requirements specified by this Permit.

12. No trenching or clearing operations shall take place until appropriate sediment controls are installed.

These devices shall not be removed until approval is granted by the WSSC.

13. All soil material deposited on public thoroughfares shall be immediately removed.

14. Topsoil shall be stripped from the construction area, stockpiled for reuse, and protected from erosion (stockpiles will be located outside of flood plains and wetlands).

15. At any locations where surface runoff from disturbed or graded areas can flow beyond the limits of disturbance, sediment control measures shall be installed and maintained to prevent sediment form being transported beyond the limits of disturbance.

16. Boring and receiving pits shall be protected with sediment control and shall be a minimum of 25ft.

from any stream and outside the 25ft. buffer for nontidal wetland with the slurry to be contained and removed from the site.

17. Any erosion and sediment control measures damaged during construction shall be repaired at the end of each working day.

18. Any groundwater that is pumped during this project shall be discharged into an approved desilting structure for dewatering before flowing off site.

19. Following initial soil disturbance or redisturbance, permanent or temporary stabilization shall be completed by the end of each workday on all disturbed areas not protected by sediment controls.

20. Should any disturbance be made to existing surface drainage channels, ditches or swales the Permittee shall restore these to their original cross-section and condition and stabilize the area with anchored sod, matting, or surge stone (4in. to 12in.).

21. Provide temporary diversions and drainage during construction in drainage ways, roadside channels, and other drainage easements with nonerodible water handling devices such as plastic sheeting, sand bags, steel plates, jersey barriers, or piping (no smaller than 12 inch diameter).

22. Final Grades shall be the same as those that existed prior to the project.

“I (WE) certify that I (WE) have the authority to make the foregoing application; that the information above and subsequent project information is correct; and that I (WE) have chosen to satisfy my(our) sediment control obligations based upon the physical characteristics of the site and my(our) ability to meet all the limitations and conditions set forth by this Agreement.”

Signature of Company Representative:_________________________________________________ Date:_________________________________________________

Printed Name:_____________________________________________________________________

Title:_____________________________________________________________________________ Address:___________________________________________________________________________

Liaison Agent’s Name:____________________________ Telephone No.______________________ Fax No._______________________

Issued by the Washington Suburban Sanitary Commission:

14501 Sweitzer Lane Laurel, MD 20707

Printed Name and Title

Signature Date

RFQ for Rehabilitation of the PI between MH31 and MH30

CONTRACTOR HEALTH & SAFETY QUALIFICATION QUESTIONNAIRE

B. SAFETY AND HEALTH PROGRAM ELEMENTS

1. Does your company have a written safety, health, and accident prevention program (SP)?

3. Does your company have a written safety incentive program that will be implemented on this project?

4. Does your company have a written accident/incident investigation procedure?

Company Name: ___________________________________________________________________ Company Type (General Contractor, Mechanical, etc.) _____________________________________

Address:

Telephone No.: ___________________ Email: __________________________ NAICS Code: ____________________

5. How many other full-time safety and health representatives are employed by your company? ____________________________

4. What professional safety and health certifications does this person hold (e.g., CSP, PE, CIH)? ______________________________

2. Does your company have a written procedure to ensure safety and health issues are preplanned into each project and work operation (e.g., JHAs, JSAs, THAs, checklists, etc.)?

6. Does your company have a written procedure to ensure that adequate safety and health program resources, such as budget, equipment, training, and manpower are included in each project bid?

. No

󠇍No

3. What percent of this person's time is spent on safety and health related matters? ______________________________ %

2. Is this a full-time position? 󠇍Yes 󠇍No Title: ___________________________________________

1. Name of Company Safety and Health Contact: ___________________________________________

A. RESOURCES

󠇍No

󠇍No

󠇍No

Contract Name:

__dddd________ddddd_

Contract Number:

Has your company operated under any other name?

If so, provide name and number of years operated.

󠇍No

Has your company performed any work for WSSC Water in the past? 󠇍

If so, under what name? ______________________________________________________________

Name of Contract(s)_______________________ Contract Number(s)_____________________________

The year(s) performed: From ___________________________ To ________________________

󠇍Yes

󠇍Yes

󠇍Yes

󠇍Yes

󠇍Yes

󠇍No 󠇍Yes

󠇍Yes kbeatty Typewritten Text kbeatty Typewritten Text kbeatty Typewritten Text

RFQ for Rehabilitation of the PI between MH31 and MH30

CONTRACTOR HEALTH AND SAFETY QAULIFICATION QUESTIONNAIRE

If yes, do your written procedures require near-miss incidents to be investigated? . Yes 󠇍No

5. Does your company have a written safety and health training program? 󠇍Yes 󠇍 No If yes, does the program include the following?

New employee/project orientation. 󠇍Yes 󠇍 No Weekly "toolbox" meetings. 󠇍Yes 󠇍 No Daily job briefings. 󠇍Yes 󠇍 No Supervisor safety training. 󠇍Yes 󠇍 No Task specific training. 󠇍Yes 󠇍 No Other: 󠇍Yes 󠇍 No

6. Does your company have a written procedure to ensure that only employees who are qualified by training and experience are allowed to operate equipment, tools, machinery, and vehicles? 󠇍Yes 󠇍No

7. Does your company designate and train competent people as required by the applicable OSHA standards (e.g., excavations, scaffold, erection, etc.)? 󠇍Yes 󠇍No

8. Does your company have a written procedure to audit projects to ensure all projects are in compliance with applicable laws, requirements, etc.? 󠇍Yes 󠇍No

9. Does your company have a written procedure to screen subcontractors based on their past safety performance? 󠇍Yes 󠇍No

12. Does your company use a screening process to ensure employees are physically able to perform work as assigned?

󠇍Yes 󠇍No

1. Does your company have a written Alcohol and drug free workplace program that includes drug testing?

C. DRUG FREE WORKPLACE PROGRAM

󠇍Yes 󠇍 No

󠇍Yes

󠇍Yes

󠇍Yes

󠇍No

󠇍No

󠇍No 13. Does your company conduct accident/incident investigations?

10. Does your company have a policy for managing sub-contractors?

11. Does your company have a contractor prequalification process in place?

14. Does your company track leading and lagging indicators?

15. Does your company provide safety training in the native 󠇍language 󠇍of 󠇍the 󠇍participants’ 󠇍and 󠇍provide material 󠇍in 󠇍the 󠇍participants’ 󠇍primary 󠇍language?

16. Does your company require OSHA 10 hour for workers and OSHA 30 hour or STS for foreman/supervisor?

󠇍Yes

󠇍Yes

󠇍Yes

󠇍No

2. If the answer to Question 1 is yes, does your written drug free workplace program include the following?

󠇍 Yes 󠇍 No 󠇍 Yes 󠇍 No 󠇍 Yes 󠇍 No 󠇍 Yes 󠇍 No 󠇍 Yes 󠇍 No

Pre-employment drug and alcohol testing.

Post-accident drug and alcohol testing.

For cause drug and alcohol testing.

Random drug and alcohol testing.

Supervisor and employee training.

D. OSHA CITATIONS

1. Has your company received any Federal or State Plan OSHA citations within the last 5 years? 󠇍Yes 󠇍No

2. If the answer to question 1 is yes, how many of each of the following types of citations have you received?

Failure to abate prior violation __________________________ Repeat __________________________ Willful __________________________ Serious __________________________ Other than Serious __________________________

Give a brief description of the nature of the citation(s), or attach a copy of the citation(s).

RFQ for Rehabilitation of the PI between MH31 and MH30

CONTRACTOR HEALTH AND SAFETY QUALIFICATION QUESTIONNAIRE

1. How many man-hours has your company worked in each of the last 3 years?

2. How many OSHA recordable injuries/illnesses did your company experience in each of the last 3 years?

Year

Year

Year

E. INJURY AND ILLNESS STATISTICS

3. Based on the below listed formula (a), what are your incident rates for each of the last 3 years?

5. Based on the below listed formula (b), what is your lost workday case (LWDC) rate for each of the last 3 years?

4. How many lost-time incidents has your company experienced in each of the last 3 years?

(a) Number of injuries and illnesses x 200,000 Man-hours worked

6. How many fatalities has your company experienced in each of the last 3 years?

9. Attach a copy of your OSHA 300A logs for the last 3 years with your completed questionnaire signed by a company executive.

7. What is your insurance Experience Modification Rate(EMR) for each of the last 3 years?

(b) LWDC x 200,000 Man-hours worked

8. Attach documentation (e.g., letters, NCCI exp.) from your insurance carrier certifying the listed EMRs.

kbeatty Typewritten Text

ATTACHMENT 1

Example Health & Safety Plan Outline

1.0 Title Page with Signature Block

2.0 Important Contacts including employer, contact name, title, cell phone, and e-mail

3.0 Organizational Structure (Identify title and responsibilities. Describe subcontractor requirements and how subcontractor safety will be assured.)

4.0 Job Hazard Analysis (Include a description of engineering controls, work practice controls, and PPE designed to reduce the risk for each hazard)

a. Chemical Hazards

b. Physical Hazards

c. Biological Hazards

5.0 Training Program

6.0 Medical Surveillance Program

7.0 Exposure Monitoring

8.0 Emergency and Accident Response (Must include a minimum of all information required by 29 CFR 1926.35)

Attachments - OSHA Required Written Programs

Attach a copy of each of the following required written programs if the hazard analysis identifies the hazard as being present on the job site.

a. Hazard Communication

b. Emergency Action Plan

c. Bloodborne Pathogens

d. Hazardous Waste Operations

e. Respiratory Protection

f. Confined Space Entry

g. Lockout / Tagout

h. Fall Protection

i. Excavations

j. Lead

9.0 Any other OSHA standard requiring a written plan.