A.03.09_Exhibits_1_of_4.pdf

EXHIBIT DESCRIPTION

A Items to be delivered at least one week prior to Pre-Work

CONTRACT

REFERENCE

C-1.6 Conference

B Mowing and Cleaning Maps C-2.14, C-2.2, C-3.1, C- 3.2g, C-5.5

C Approximate Quantities by Area C-3.1

D Accident Prevention Plan (APP) Outline C-1.6 d

E Partial listing of Safety Requirements C-2.12

F Safety Forms OSAH Form 300; Accident Investigation

C-1.9 d Report ENG 3394

G Quality Control Plan C-1.6a; C1.18

H Quality Assurance Plan (QASP) C-1.19

I Sample Work Schedule C-1.21

J Sample Invoice None

K Government Furnished Equipment List C-1.24 a

L Task Order C-1.3, C-1.27

M Job Request Form, CELRH 2770 C-1.33

N Contract Discrepancy Form, CELRH 1104 C-1.16

0 Contractor Equipment & Inspection Forms 2880 C-1.25 d, 2.13b p Vehicle Operations CELRH 2796, CELRH 2813, ENG

C-1.24a Form 4900-R, ENG Form 4866

Q Inspection Forms: CELRH 2788, ·2773-2, 2773-3, 2773-5, C-3.2k

2773-10, & CELRH 2790

Item Description Yes No N/A

1. Signature sheet

a. Includes the name, signature, and title of the Plan Preparer (Qualified person, i.e. corporate safety staff person, QC )

b. Includes the name, signature, and title of the Plan Approver (e.g. owner, company president, regional vice president ) (HTRW activities require approval of a Certified Industrial Hygienist, a Certified Safety Professional may approve the plan for operations involving UST removal where contaminants are known to be petroleum, oils, or lubricants).

c. Includes the name(s), signature(s), and title(s) for Plan Concurrence (provide concurrence of other applicable corporate and project personnel (contractor)) (e.g. Chief of Operations, Corporate Chief of Safety, Corporate Industrial Hygienist, project manager or superintendent, project safety professional, project

QC. )

2. Background information

a. Includes the Contractor Name.

b. Includes the Contract Number.

c. Includes the Project Name.

d. Includes the Brief Project Description.

e. Includes the Location of the Project (map).

f. Includes the Contractor Accident Experience (Copy of OSHA

g. Includes the Listing of Phases of Work and Hazardous Activities Requiring an Activity Hazard Analyses (AHA).

3. Statement of Safety and Health Policy. Includes a copy of the corporate safety policy. (In addition to the corporate policy statement, a copy of the corporate safety program may provide a portion of the information required by the accident prevention

4. Responsibilities and Lines of Authorities

a. Includes the identification and job responsibilities of personnel responsible for safety - at both corporate and project level – including their resumes.

b. Includes the lines of authority.

CESO Form A-02 Sep 13

Remarks (Any NO or N/A item)

Form A-02 U.S. Army Corps of Engineers

Accident Prevention Plan Checklist

Date of Inspection

Location (Plant or Facility) Contract Number

Contractor Name Project Name

Inspector Name (Print) Inspector Signature

This checklist serves as a guide only, it does not replace or eliminate the need to comply with the requirements set forth in Engineering Manual 385-1-1, Safety and Health Requirements Manual, dated XX Sept 2014. The references included in this checklist correspond to the applicable sections of EM 385-1-1.

Item Description Yes No N/A

5. Training

a. Includes the list of subjects to be discussed with employees at safety indoctrination.

b. Includes the list of mandatory training and certifications applicable to this project (e.g., explosive actuated tools, confined space entry, crane operator, diver, vehicle operator, HAZWOPER training and certification, PPE ) and any requirements for periodic retraining / recertification.

c. Includes the identity requirements for emergency response training.

d. Includes the outline requirements (who attends, when given, who will conduct, etc. ) for supervisory and employee safety

6. Safety and Health Inspections

a. Includes the name(s) of individual(s) responsible for conducting safety inspections. (e.g., PM, safety professional, QC, supervisors, employees )

b. Includes proof of inspector's training / qualifications.

c. Indicates when inspections will be conducted.

d. Furnished sample forms upon which inspections will be recorded.

e. Indicates deficiency tracking system and follow-up procedures.

f. Includes the names of competent and / or qualified person(s) and proof of competency / qualification to meet specific OSHA competent / qualified person(s) requirements.

g. Includes any external inspections / certifications which may be required. (e.g., US Coast Guard )

7. Safety and Health Expectations, Incentive Programs, and Compliance

a. Includes the company's written safety program goals, objectives, and accident experience goals.

b. Includes a brief description of the company's safety incentive programs (if any ).

c. Includes the policies and procedures regarding noncompliance with safety requirements (to include disciplinary actions for violation of safety requirements).

d. Includes the written company procedures for holding managers and supervisors accountable for safety.

8. Mishap Reporting

a. The plan identifies how, when, and who shall complete the Exposure data (man-hours worked).

b. The plan identifies how, when, and who shall complete mishap investigations, reports, and logs.

c. The plan identifies how, when, and who shall make immediate notification of major mishaps.

CESO Form A-02 Sep 13

Remarks (Any NO or N/A item)

Form A-02 U.S. Army Corps of Engineers

Accident Prevention Plan Checklist (cont’d)

Date of Inspection