W912HN-09-R-0109-SPECS-ER-Calhoun.pdf

Lake Marion Regional Water System Project:

Elloree Reach - Calhoun Reach Water Transmission Main near Town Of Elloree and areas within Orangeburg County, South Carolina W912HN-09-R-0109

TECHNICAL PROVISIONS-TABLE OF CONTENTS

COVER PAGE

DOCUMENTS 00 - INTRODUCTORY, BIDDING, AND CONTRACT REQUIREMENTS

00101N BID SCHEDULES

00102N LIST OF DRAWINGS

DIVISION 01 - GENERAL REQUIREMENTS

01100 GENERAL REQUIREMENTS

01110N SUMMARY OF WORK

01270A MEASUREMENT AND PAYMENT

01312A QUALITY CONTROL SYSTEM (QCS)

01320A PROJECT SCHEDULE

01330 SUBMITTAL PROCEDURES

01355A ENVIRONMENTAL PROTECTION

01420 SOURCES FOR REFERENCE PUBLICATIONS

01451A CONTRACTOR QUALITY CONTROL

01500A TEMPORARY CONSTRUCTION FACILITIES

01525 SAFETY AND OCCUPATIONAL HEALTH REQUIREMENTS

01780A CLOSEOUT SUBMITTALS

01781 OPERATION AND MAINTENANCE DATA

DIVISION 02 - SITE CONSTRUCTION

02231 CLEARING AND GRUBBING

02240 BORING AND JACKING

02250 HORIZONTALLY DIRECTIONALLY DRILLED, PIPE (HOD)

02300 EARTHWORK

02370A SOIL SURFACE EROSION CONTROL

02570A MANHOLES

02600 WATER MAINS

02700 UNDERGROUND PACKAGED MASTER METER STATION

02713A BITUMINOUS BASE COURSE

02723A AGGREGATE BASE COURSE

02732 AGGREGATE SURFACE COURSE FOR METER VAULT SITE

02831 CHAIN LINK FENCES AND GATES

02921A SEEDING

02960 TRAFFIC CONTROL

DIVISION 16 - ELECTRICAL

16051 GENERAL ELECTRICAL FOR MASTER METER STATION SITEWORK

APPENDICES

APPENDIX 1: GEOTECHNICAL EXPLORATION AT NORTH TEE VEE ROAD METER VAULT SITE

APPENDIX 2: GEOTECHNICAL EXPLORATION AT SANTEE (HWY 6) METER VAULT SITE

APPENDIX 3: GEOTECHNICAL EXPLORATION AT SOUTH TEE VEE ROAD METER VAULT SITE

APPENDIX 4: USACE EP 310-1-6

APPENDIX 5: AGREEMENT NO. CSX640127

APPENDIX 6: SCDOT RIGHT-OF-WAY ENCROACHMENT PERMIT, PERMIT NUMBER: 72830

APPENDIX 7: SCDOT RIGHT-OF-WAY ENCROACHMENT PERMIT, PERMIT NUMBER: 76809

APPENDIX 8: SCDOT RIGHT-OF-WAY ENCROACHMENT PERMIT, PERMIT NUMBER: 77337

APPENDIX 9: ORANGEBURG COUNTY PUBLIC WORKS DEPARTMENT,ENCROACHMENT PERMIT FOR

USE OF RIGHT-OF-WAY, PERMIT NUMBER: 8-09-350

APPENDIX 10: SCDHEC WATER SUPPLY CONSTRUCTION PERMIT, PERMIT NUMBER: 26960-WS

APPENDIX 11: NPDES GENERAL PERMIT FOR STORM WATER DISCHARGES FROM LARGE AND

SMALL CONSTRUCTION ACTIVITIES PERMIT NUMBER: SCR10L094

APPENDIX 12: NPDES GENERAL PERMIT FOR STORM WATER DISCHARGES FROM LARGE AND

SMALL CONSTRUCTION ACTIVITIES PERMIT NUMBER: SCR10L648

ATTACHMENTS

Appendix 1 , Page 1

Appendix 1 , Page 2

Appendix 1 , Page 3

Appendix 1 , Page 4

Appendix 1 , Page 5

Appendix 1 , Page 6

Appendix 1 , Page 7

Appendix 1 , Page 8

Appendix 1 , Page 9

Appendix 1 , Page 10

Appendix 1 , Page 11

Appendix 1 , Page 12

Appendix 1 , Page 13

Appendix 1 , Page 14

Appendix 1 , Page 15

Appendix 2, Page 1

Appendix 2, Page 2

Appendix 2, Page 3

Appendix 2, Page 4

Appendix 2, Page 5

Appendix 2, Page 6

Appendix 2, Page 7

Appendix 2, Page 8

Appendix 2, Page 9

Appendix 2, Page 10

Appendix 2, Page 11

Appendix 2, Page 12

Appendix 2, Page 13

Appendix 2, Page 14

Appendix 2, Page 15

Appendix 2, Page 16

Appendix 2, Page 17

Appendix 3, Page 1

Appendix 3, Page 2

Appendix 3, Page 3

Appendix 3, Page 4

Appendix 3, Page 5

Appendix 3, Page 6

Appendix 3, Page 7

Appendix 3, Page 8

Appendix 3, Page 9

Appendix 3, Page 10

Appendix 3, Page 11

Appendix 3, Page 12

Appendix 3, Page 13

Appendix 3, Page 14

Appendix 3, Page 15

Appendix 3, Page 16

Appendix 3, Page 17

Appendix 4, Page 1

Appendix 4, Page 2

Appendix 4, Page 3

Appendix 4, Page 4

Appendix 4, Page 5

Appendix 4, Page 6

Appendix 4, Page 7

Appendix 4, Page 8

Appendix 4, Page 9

Appendix 4, Page 10

Appendix 4, Page 11

Appendix 4, Page 12

Appendix 5, Page 1

Appendix 5, Page 2

Appendix 5, Page 3

Appendix 5, Page 4

Appendix 5, Page 5

Appendix 5, Page 6

Appendix 5, Page 7

Appendix 5, Page 8

Appendix 5, Page 9

Appendix 5, Page 10

Appendix 5, Page 11

Appendix 5, Page 12

Appendix 5, Page 13

Appendix 5, Page 14

Appendix 5, Page 15

Appendix 5, Page 16

Appendix 5, Page 17

Appendix 5, Page 18

Appendix 5, Page 19

Appendix 5, Page 20

Appendix 5, Page 21

Appendix 5, Page 22

Appendix 5, Page 23

Appendix 5, Page 24

Appendix 6, Page 1

Appendix 7, Page 1

Appendix 7, Page 2

Appendix 8, Page 1

Appendix 9, Page 1

Appendix 9, Page 2

Appendix 10, Page 1

Appendix 11, Page 1

Appendix 11, Page 2

Appendix 11, Page 3

Appendix 11, Page 4

Appendix 11, Page 5

Appendix 12 , Page 1

Appendix 12 , Page 2

Appendix 12 , Page 3

Appendix 12 , Page 4

Appendix 12 , Page 5

Lake Marion Regional Water System Project, W912HN-09-R-0109 Elloree - Calhoun Reach Water Transmission Main near the Town of Elloree and areas within Orangeburg County, South Carolina

ATTACHMENTS

DESCRIPTION No. Of

PAGES

A CONSTRUCTION QUALITY CONTROL REPORT 2

B DEFICIENCY TRACKING LOG 1

C LOG AND SUMMARY OF OCCUPATION INJURIES AND

ILLNESSES (OSHA FORM 300) 3

D MINIMUM BASIC OUTLINE FOR ACCIDENT PREVENTION PROGRAM 7

E ACTIVITY HAZARD ANALYSIS 1

F REPORT OF WEEKLY SAFETY MEETING (SAC FORM 253) 1

G-1 SAD FORM 1437a-R, FLOATING PLANT OMITTED

G-2 SAD FORM 1437b-R, LAUNCHES, MOTORBOATS, AND SKIFFS OMITTED

G-3 SAD FORM 1666a-R, CRAWLER, TRUCK, AND WHEEL MOUNTED CRANES 4

G-4 SAD FORM 1666b-R, PORTAL, TOWER, AND PILLAR CRANES 2

G-5 SAD FORM 1666c-R, RIGGING 4

G-6 SAD FORM 1666d-R, MOTOR VEHICLES, TRAILERS, AND TRUCKS 3

G-7 SAD FORM 1666e-R, CRAWLER TRACTORS AND DOZERS 2

G-8 SAD FORM 1666f-R, SCRAPERS, MOTOR GRADERS, AND

OTHER MOBILE EQUIPMENT 3

G-9 SAD FORM 1666g-R, MATERIAL HOISTS 1

G-10 SAD FORM 1666h-R, EARTH DRILLING EQUIPMENT 1

H SUBMITTAL REGISTER (ENG 4288-R) 8

H-1 TRANSMITTAL OF SHOP DRAWINGS, EQUIPMENT DATA, MATERIAL

SAMPLES,MANUFACTURERS CERTIFICATES COMPLIANCE (ENG FORM 4025-R) 2

I DISCLOSURE OF LOBBYING ACTIVITIES Standard Form LLL 3

J OMITTED

K OMITTED

L WAGE RATES 3

M CONSTRUCTION PROGRESS CHART 1

N MINIMUM STANDARD FOR TEMPORARY ELECTRICAL SERVICE 1

O ELECTRICAL SERVICE REQUIREMENTS FOR CONSTRUCTION AND

MAINTENANCE OPERATIONS 11

A-1 ATTACHMENT A

FORMAT

CONTRACTOR’S NAME

(Address)

CONSTRUCTION QUALITY CONTROL REPORT

Date:__________________ Report No.__________________

Contract No.___________________________

Description and Location of Work:__________________________________________

Weather: (Clear) (P. Cloudy) (Cloudy): Temperature:_______-Min,_______Max:;

Rainfall________Inches

Contractor/Subcontractors and Area of Responsibility .

a. ___________________________________________________________________

b. ___________________________________________________________________ c.____________________________________________________________________ d.____________________________________________________________________ e.____________________________________________________________________ f.____________________________________________________________________ g.____________________________________________________________________

1. Work Performed Today:

(Indicate location and description of work performed. Refer to work performed by prime and/or subcontractors by letter in Table above.)

2. Results of Control Activities:

(Indicate whether: P-Preparatory, I-Initial, or F-Follow-up and include satisfactory work completed or deficiencies with action to be taken.)

A-2 ATTACHMENT A

3. Test Required by Plans and/or Specifications Performed and Results of Tests:

4. Monitoring of Materials and Equipment:

5. Off-Site Surveillance Activities:

6. Job Safety and Health Deficiencies:

(Daily Comment Required)

7. Remarks:

a. (Cover any conflicts in plans and specifications or instructions.)

b. (Action taken in review of submittal.)

c. (Verbal instructions received.)

CONTRACTOR’S VERIFICATION:

The above report is complete and correct and all material and equipment used and work performed during this reporting period are in compliance with the contract plans and specifications except as noted above.

Chief of Contractor Quality Control

B-1 ATTACHMENT B

DEFICIENCY TRACKING LOG

DEFICIENCY

NUMBER

INITIAL REPORT SCHEDULED

Corrective Action

When Corrected REMARKS

Report# DATE* Report# DATE Report# DATE**

*Include initials of who identified deficiency ** Include initials of who corrected deficiency Log Prepared by:___________________________

Year

City State

(A) (B) (C) (D) (E) (F)

(M)

(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)

Page totals 0 0 0 0 0 0 0 0 0 0 0 0

Page 1 of 1 (1) (2) (3) (4) (5) (6)

Other record-able cases H ea rin g Lo ss

A ll ot he r i lln es se s

Away From Work (days) A ll ot he r i lln es se s

S ki n D is or de r

Form approved OMB no. 1218-0176

Establishment name

CHECK ONLY ONE box for each case based on the most serious outcome for that case:

Enter the number of days the injured or ill worker was:

Identify the person Describe the case

Date of injury or onset of illness

In ju ry

Death

Case No.

P oi so ni ng P oi so ni ng

H ea rin g

Lo ss

In ju ry

S ki n D is or de rBe sure to transfer these totals to the Summary page (Form 300A) before you post it.

Days away from work Remained at work

R es pi ra to ry

C on di tio n

R es pi ra to ry

C on di tio n

On job transfer or restriction

(days)Job transfer or restriction

(mo./day)

Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. U.S. Department of Labor

Occupational Safety and Health Administration

Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review the instruction, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office.

Log of Work-Related Injuries and Illnesses

Employee's Name

You must record information about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR 1904.8 through 1904.12. Feel free to use two lines for a single case if you need to. You must complete an injury and illness incident report (OSHA Form 301) or equivalent form for each injury or illness recorded on this form. If you're not sure whether a case is recordable, call your local OSHA office for help.

OSHA's Form 300 (Rev. 01/2004)

Job Title (e.g., Welder)

Where the event occurred (e.g.

Loading dock north end)

Describe injury or illness, parts of body affected, and object/substance that directly injured or made person ill (e.g. Second degree burns on right forearm from acetylene torch)

Classify the case

Check the "injury" column or choose one type of illness:

Attachment C-1

Year

Street

City Zip

0 0 0 0

(G) (H) (I) (J) OR

0 0

(K) (L)

Total number of… Knowingly falsifying this document may result in a fine.

(M)

(1) Injury 0 (4) Poisoning 0

(2) Skin Disorder 0 (5) Hearing Loss 0

(3) Respiratory Condition 0 (6) All Other Illnesses 0

Industry description (e.g., Manufacture of motor truck trailers)

Post this Summary page from February 1 to April 30 of the year following the year covered by the form

All establishments covered by Part 1904 must complete this Summary page, even if no injuries or illnesses occurred during the year. Remember to review the Log to verify that the entries are complete

Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you've added the entries from every page of the log. If you had no cases write "0."

Employees former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or its equivalent. See 29 CFR 1904.35, in OSHA's Recordkeeping rule, for further details on the access provisions for these forms.

Total number of cases with days away from work

Total number of cases with job transfer or restriction

Total number of days away from work

Total number of days of job transfer or restriction

Public reporting burden for this collection of information is estimated to average 50 minutes per response, including time to review the instruction, search and gather the data needed, and complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office.

Injury and Illness Types

U.S. Department of Labor

OSHA's Form 300A (Rev. 01/2004)

Summary of Work-Related Injuries and Illnesses Occupational Safety and Health Administration

Form approved OMB no. 1218-0176

Title

Date

Establishment information

Total number of deaths

Number of Cases

Total number of other recordable cases

Number of Days

Total hours worked by all employees last year

Standard Industrial Classification (SIC), if known (e.g., SIC 3715)

Annual average number of employees

North American Industrial Classification (NAICS), if known (e.g., 336212)

Phone

Company executive

I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and complete.

Sign here

State

Employment information

Your establishment name

1) 10)

2) 11)

State Zip 12) AM/PM

3) 13) AM/PM

4) 14)

5)

15) 6)

7)

16)

State Zip

8) Yes 17)

No

9) Date Yes

No 18)

U.S. Department of Labor Occupational Safety and Health Administration

Form approved OMB no. 1218-0176

Information about the employee Information about the case

Case number from the Log

Was employee hospitalized overnight as an in-patient?

Was employee treated in an emergency room?

City

If you need additional copies of this form, you may photocopy and use as many as you need.

(Transfer the case number from the Log after you record the case.)Full Name

Street

City

Date of birth

Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers' compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this form.

According to Public Law 91-596 and 29 CFR 1904, OSHA's recordkeeping rule, you must keep this form on file for 5 years following the year to which it pertains

Time employee began work

This Injury and Illness Incident Repor t is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related injuries and Illnesses and the accompanying Summary , these forms help the employer and OSHA develop a picture of the extent and severity of work-related incidents.

Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes.Injuries and Illnesses Incident Report

If treatment was given away from the worksite, where was it given?

Facility

Street

Male

Name of physician or other health care professional

Female

Information about the physician or other health care professional

Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistics, Room N-3644, 200 Constitution Ave, NW, Washington, DC 20210. Do not send the completed forms to this office.

What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine";

"radial arm saw." If this question does not apply to the incident, leave it blank.

Title

Time of event Check if time cannot be determined

Date hired

Date of injury or illness

What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily computer key-entry."

Completed by

Phone

What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement";

"Worker developed soreness in wrist over time."

OSHA's Form 301

What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than "hurt", "pain", or "sore." Examples: "strained back"; "chemical burn, hand"; "carpal tunnel syndrome."

If the employee died, when did death occur? Date of death

D-1 ATTACHMENT D

MINIMUM BASIC OUTLINE FOR ACCIDENT PREVENTION PROGRAM

This outline is intended to be a guide and may be incomplete dependent on the type of operations to be performed. Its only purpose is to assist the contractor when submitting his proposal for carrying out the accident prevention provisions of the contract. When composing the proposals the Contractor must be mindful to be relevant, specific, and not copy or reproduce statements from safety regulations. Rather, his submitted proposals are to relate “how, who, why, what, where” he plans to perform the contracted work requirements in a safe manner using the Safety and Health Requirements Manual, EM 385-1-1, current revisions to date. Non-applicable parts of this outline should be disregarded.

1. CONTRACT NO: DATE SUBMITTED:

2. CONTRACTORS NAME, ADDRESS AND TELEPHONE NO:

3. PROJECT LOCATION:

4. CONTRACTORS PAST SAFETY RECORD: (Including work with other Districts.)

A. Analysis of Accident experience

B. Years experience covers

C. Types of Accidents

D. Causes of Accidents

E. Corrective measures taken

F. Statement giving percent debit or credit of annual rate of compensation insurance

5. INVESTIGATION: All accidents investigation for the purpose of preventing similar accidents and gather facts

A. Procedures used in investigation accidents

B. Completeness and promptness of reports

6. SAFETY INSPECTIONS:

A. Who will perform these inspections

B. How often will they be conducted

D-2 ATTACHMENT D

C. What items will be inspected

1) Hand Tools

2) Equipment

3) Motor Vehicles

4) Housekeeping

5) Safe work practices

6) Sanitation

7) Personal Protective Equipment

7. SAFETY TRAINING

A. Orientation and Instruction of new employee (safety topics)

B. Who will give the orientation and instruction

C. Knowledge of Corps of Engineers Safety Requirements

8. SAFETY MEETINGS:

A. Who will conduct safety meetings

B. What subjects will be discussed

C. How often will meetings be conducted

D. When will reports of these meetings be submitted

E. Do you have an incentive program for safety consciousness

F. Who will administer your overall Accident prevention Program

9. HEALTH AND SANITATION:

A. Drinking Water

1) Source

2) Type of Dispensing Unit

a. methods

b. care of units

D-3 ATTACHMENT D

B. Toilet Facilities

1) Location

2) Type of Unit

3) Quantity

4) Service Frequency

C. Housing and/or office facilities

1) Location

2) Type of Accommodations

D. Medical Facilities

1) First Aid Capabilities

a. Number of trained personnel and certificate of qualifications

b. Number and type of first aid kits and supplies

c. How often are instructions given to employees

2) Professional care and services (names, addresses and phone numbers)

a. Local physicians

b. Hospital Facilities

c. EMS or Ambulance Service

3) Emergency Evacuation for Critically Injured personnel

a. Procedure

b. Helicopter Service and Phone Number

10. FIRE PREVENTION AND PROTECTION:

A List your Fire Fighting Personnel

1) Who has definite responsibility

2) How often are personnel trained

B. Fire Fighting Equipment/Extinguishers

1) Type of Service

2) Is it adequate

D-4 ATTACHMENT D

3) Where is it located

4) When is maintenance and inspection performed

C. Flammable

1) Types stored

2) How stored (methods)

3) Where stored (containers, cabinets, etc)

4) Dispensing methods

11. PERSONAL PROTECTIVE EQUIPMENT (PPE): (Safety hats, goggles, personal flotation devices, safety shoes, respirators, etc.

A. Provided

B. Use required

C. Maintenance of PPE

D. Storage

12. LIGHTING:

A. On mobile equipment

B. Work areas

C. Access to work areas

13. TRANSPORTING PERSONNEL:

A. Equipment used

1) Design

2) Capacity

3) Maintenance and frequency

B. Operators and Qualifications

14. MACHINERY AND EQUIPMENT: (includes floating plant)

A. Number and type equipment

B. Pre-work safety checks

C. Guards and safety devices

D-5 ATTACHMENT D

D. Maintenance and Servicing

E. Load tests

F. Operating Personnel

1) Qualifications and Certification

2) Responsibilities

3) Observance of instructions, etc.

15. CLEARING OPERATIONS:

A. Burning

16. ACCESS FACILITIES:

A. Ladders

B. Stairways

17. HANDTOOLS

A. Electric

B. Pneumatic

C. Explosive activated

D. Other (specify)

18. WELDING AND BURNING OPERATIONS:

A. Type Equipment

B. Personal Protective Equipment and Devices

C. Storage of compressed cylinders (full and empty)

D. Safe practices

19. HEATING DEVICES:

A. Types

B. Fuel

C. Maintenance

D. Locations

20. RIPRAP - METHODS OF PLACEMENT:

D-6 ATTACHMENT D

21. PROTECTION OF THE PUBLIC:

A. Visitors

B. Pedestrians

C. Motor vehicles

D. Controls and procedures

22. HOUSEKEEPING POLICY:

A. Procedures

B. Methods

C. Debris Disposal

23. EXCAVATIONS:

A. Type

B. Depth

C. Shoring

D. Sloping

24. WATER SAFETY:

A. Type and size floating plant

B. Use of personal protective equipment (PPE)

C. Life saving skiff

D. Lifesaving and rescue drills

E. Diving policy and notifications procedures (Separate plan must be submitted)

25. ELECTRICAL WIRING

A. Voltage and uses

B. Elevated and/or buried

C. Grounding

D. Ground fault circuit interrupters (GFCI’s)

E. Operators adjacent to overhead lines

D-7 ATTACHMENT D

26. NOISE ABATEMENT:

A. Hearing Conservation Program

B. Source

C. Exposure controls (PPE)

27. HAZARD COMMUNICATION PROGRAM:

A. Description of Company Policy

B. Materials Safety Data Sheets (MSDS)

C. Communication Methods with Employees

28. ALCOHOL AND DRUG POLICY:

29. COMPLIANCE STATEMENT:

(All work will be performed in accordance with Corps of Engineers’ Safety and Health Requirements Manual, EM 385-1-1, and current revisions to date, and will included any additional measures the Contracting Officer deems necessary for the prevention of Accidents.)

30. OTHER SAFETY HAZARDS:

(Describe any other hazards you may anticipate for this particular job and those measures that will be taken to eliminate them.)

31. ACTIVITY HAZARD ANALYSIS:

EM 385-1-1, requires an Activity Hazards Analysis to be prepared by the Contractor. This (phase plan) will be attached to the accident prevention plan. Work will not proceed until these plans have been accepted by the Government.

This plan has been reviewed and determined appropriate for the safe operations of this job.

PRIME CONTRACTOR

AUTHORIZED REPRESENTATIVE

OF THE CONTRACTING OFFICER

USACE SAFETY OFFICER

E-1 ATTACHMENT E

ACTIVITY HAZARD ANALYSIS

ACTIVITY______________________ANALYZED BY/DATE___________________REVIEWED BY/DATE___________

PRINCIPAL STEPS POTENTIAL HAZARDS RECOMMENDED CONTROLS

Identify the principal steps involved and the sequence of work activities

Analyze each principal step for its potential hazards

Develop specific controls for each potential hazard.

EQUIPMENT TO BE USED INSPECTION REQUIREMENTS SUPERVISORY REQUIREMENT TRAINING REQUIREMENT

List of equipment/machinery to be used in conducting the work activities.

List inspection requirements for the equipment/machinery listed.

List the names of the individuals responsible for the safe execution of these activities

Determine requirements for worker training including hazard communicaton.

SAC Form 253 F-1 ATTACHMENT F

01 FEB 1985

REPORT OF WEEKLY SAFETY MEETING__________________________________

(DR 385-1-4)

TO: Chief, Safety Office FROM

DATE:____________________________ TIME: (A.M./P.M.)

No. Employees Present_______________ Duration:__________________________

Old Business: (Review report of last meeting. Follow up on action taken or anticipated to correct any safety deficiencies brought up at last meeting. Discuss any unfinished business.)

New Business: (Discuss any unsafe acts or conditions observed since last safety meeting and any mishaps or injuries which occurred during the week.)

Safety Presentation: Safety talk, movie, or slide presentation on subject that is relevant to operation at hand.)

SIGNATURE & DATE

Government Representative

SIGNATURE & DATE

Contractor Safety Representative

G-3-1 ATTACHMENT G-3

SAFETY CHECKLIST FOR CRAWLER-, TRUCK-,

WHEEL-, RINGER-MOUNTED CRANES

Contract # and title:

Equipment name & number:

owned or leased?

Contractor:

Subcontractor:

Contract Inspector: Date inspected:

This checklist references EM 385 1-1, revised 3 November 2003 Yes No N/A

1. Unless the manufacture has specified an on-rubber rating, outriggers will be fully extended and down? (16.D.10)

2. Are lattice boom cranes equipped with a boom angle indicator, load indicating device, or a load moment indicator? (16.D.01)

3. Are lattice boom and hydraulic cranes equipped with a means for the operator to visually determine levelness? (16.D.02)

4. Are lattice boom and hydraulic cranes, except articulating booms cranes, equipped with drum rotation indicators located for use for the operator?

(16.D.03)

5. Are lattice boom and hydraulic mobile cranes equipped with a boom angle or radius indicator within the operator’s view? (16.D.04)

6. Are lattice boom cranes, with exception of duty cycle cranes, equipped with an anti-two blocking device? (16.D.04)

7. When duty cycle machines are required to make a non-duty lift, is the crane equipped with an international orange warning device and is a signal person present? (16.D 05)

8. Are the following with the crane at all times: (16.C.02)

a. The manufacturer’s operating manual?

b. The load-rating chart?

c. The crane’s logbook documenting use, maintenance, inspections and tests?

d. Operating manual for crane operator aids used on the crane.

SAD Form 1666a-R Previous editions may be used for contract submittals prior to Nov 03.

Reference: EM 385-1-1, 3 November 2003 edition.

G-3-2 ATTACHMENT G-3

9. Are the following on the project site:

a. Completed periodic inspection report prior to initial work? (16.C.12)

b. Pre-operational checklist used for daily inspection? (16.C.12)

c. Written reports of the operational performance test? (16.C.13)

d. Written reports of the load performance test?

(16.C.13)

10. Are all operators physically qualified to perform work? (16.C.05)

11. Are all operators qualified by written/oral and practical exam or by appropriate licensing agency for the type crane they are to operate? (16.C.05)

12. Is the crane designed and constructed IAW the standards listed in Table 16-1? (16.C.06)

13. Is a hazard analysis for set-up and set-down available? (16.C.08)

14. Are accessible areas within the swing radius of the rear of the crane barricaded? (16.C.09)

15. Are there at least 3 wraps of cable on the drum? (16.C.10)

16. Are the hoisting ropes installed IAW the manufacturer’s recommendations? (16.C.10)

17. Are critical lift plans available? (16.C.18)

18. Are minimum clearance distance for high voltage lines posted at the operator’s position? (11.E.04)

19. Do older lattice boom cranes with anti-two block warning devices in lieu of anti-two block devices have manually activated friction brakes? (16.D.05)

20. Is the slow moving emblem used on all vehicles which by design move at 25 MPH or less on public roads? (08.A.04)

21. Are all vehicles which will be parked or moving slower than normal traffic on haul roads equipped with a yellow flashing light or flasher visible from all directions? (16.A.13)

G-3-3 ATTACHMENT G-3

22. Is all equipment to be operated on public roads provided with: (16A.07)

a. Headlights?

b. Brake lights?

c. Taillights?

d. Back-up lights?

e. Front and rear turn signals?

Yes No N/A

23. Are seat and seat belts provided for the operator and each rider on equipment? (16.A.07 and 16.B.08)

24. Is all equipment with windshields equipped with powered wipers and defogging or defrosting devices? (16.A.07)

25. Is the glass in the windshield or other windows clear and unbroken to provide adequate protection and visibility for the operator? (16.A.07, 16.B.10)

26. Is all equipment equipped with adequate service brake system and emergency brake system? (16.A.18)

27. Are areas on equipment where employees walk or climb equipped with platforms, footwalks, steps, handholds, guardrails, toeboards and non-slip surfaces? (16.B.03)

28. Is all self-propelled equipment equipped with automatic, audible, reverse signal alarms? (16.B.01)

29. Is there a record of manufacturer’s approval of any modification of equipment which affects its capacity or safe operation? (16.A.19)

30. Are truck and crawler cranes attached to a barge or pontoon by means of a tie-down system with some slack? Movement during lifting is not permitted.

(16.F.08)

31. Have the following conditions been met for land cranes mounted on barges or pontoons: (16.F.06)

a. Have load ratings been modified to reflect the increased loading from list, trim, wave, and wind action?

b. Are all deck surfaces above the water?

c. Is the entire bottom area of the barge or pontoon submerged?

d. Are tie downs available?

e. Are cranes blocked and secured?

32. Are all belts, gears, shafts, spindles, drums, flywheels, or other rotating parts of equipment guarded where is a potential for exposure to workers?

(16.B.03)

G-3-4 ATTACHMENT G-3

33. Is the area where the crane is to work level, firm and secured? (16.A.10)

34. Is a dry chemical or carbon dioxide fire extinguisher rated at least 5-B:C on the crane? (16.A.34)

35. Are trucks, for truck-mounted cranes, equipped with a working reverse signal alarm? (16.B.01)

36. Is a signal person provided where there is danger from swinging loads, buckets, booms, etc.? (16.B.02)

37. Is there adequate clearance from overhead structures and electrical sources for the crane to be operated safely? (16.C.09)

38. Is there adequate lighting for night operations? (16.C.19)

39. Has the boom stop test on cable-supported booms been performed?

(16.D.06)

40. Is the boom disengaging device functioning as required? (16.D.06)

41. Has all rigging and wire rope been inspected? (Section 15)

Remarks:(Enter actions taken for all “no” answers.)

Contractor inspector signature

Contractor QC/safety officer/project manager signature

G-4-1 ATTACHMENT G-4

SAFETY CHECKLIST FOR PORTAL, TOWER, AND

PILLAR CRANES

Contract # and Title:

Equipment name & number:

Owned or leased?

Contractor: Subcontractor:

Contract Inspector: Date Inspected:

1. Are the following available: (16.E.02)

a. Manufactures written erection instructions?

b. Listing of the weight of each component?

c. An activity hazard analysis for the erection?

d. Does the activity hazard analysis contain (1.) Location of crane and adjacent structures?

(2.) Foundation design and construction Requirements?

(3.) Clearance and bracing requirements?

2. Is there a boom angle indicator within the operator’s view? (16.E.04)

3. Are luffing jib cranes equipped with: (16.E.05)

a. Shock absorbing jib stops?

b. Jib hoist limit switch?

c. Jib angle indicator visible to operator?

4. If used, do rail clamps have slack between the point of attachment to the rail and the end fastened to the crane? (16E.06)

5. Are the following with the crane at all times: (16.C.02)

a. The manufacturer’s operating manual?

b. The load-rating chart?

c. The crane’s logbook documenting use, maintenance, inspections and tests?

d. The operating manual for crane operational aids used on the crane?

SAD Form 1666b-R Previous editions may be used for contract submittals prior to Nov 03.

G-4-2 ATTACHMENT G-4

6. Are all crane and derrick inspections performed by a qualified person?

(16.C.12)

7. Are the following on the project site:

a. Completed periodic inspection report prior to initial work?

(16.C.12 and Appendix H)

b. Pre-operational checklist used for daily inspections? (16.C.12)

c. Written reports of the operational performance tests? (16.C.13)

d. Written reports of the load performance tests? (16.C.13)

8. Is every crane operator certified by a physician to be physically qualified to perform work? (16.C.05)

9. Are all operators qualified by written and practical exam or by appropriate licensing agency for the type crane they are to operate? (16.C.05)

10. Is the crane designed and constructed IAW the standards listed in Table 16-1? (16.C.05)

11. Is a activity hazard analysis for set-up and set-down available? (16.C.08)

12. Are there at least 3 wraps of cable on the drum? (16.C.10)

13. Are the hoisting ropes installed IAW the manufacturer’s recommendations? (16.C.10)

14. Is the record of manufacturer’s approval of any modification of equipment which affects its capacity or safe operation? (16.A.07)

15. Remarks: (Enter actions taken)

SAD Form 1666b-R Previous editions may be used for contract submittals prior to Nov 03.

G-5-1 ATTACHMENT G-5

SAFETY CHECKLIST FOR RIGGING

Contract # and title:

Equipment name & number:

Contractor

Contractor inspector:

Date inspected:

1. Is rigging equipment inspected IAW manufacturer specifications, by a competent person prior to use on each shift? (15.A.01)

2. Has all defective rigging been removed? (15.A.01)

3. Is rigging stored properly? (15.A.01)

4. Are running lines within 6.5’ of the ground or working level guarded by a physical barriers? (15.A.03)

5. Are all eye splices made in an approved manner with rope thimbles? (Sling eyes excepted) (15.A.04)

6. Are positive latching devices used to secure loads? (15.A.05)

7. Are all custom lifting accessories marked to indicate their safe working loads? (15A.07)

8. Are all custom designed lifting accessories proof-tested to 125% of their rated load? (15.A.07)

9. Are the following conditions met for wire rope: (15.B.01-09)

a. Are they free of rust or broken wires?

b. Are defective ropes cut up or marked as unusable?

c. Do rope clips attached with U-bolts have the U-bolts on the dead end or short end of the rope?

d. Are protruding ends of strands in splices on slings and bridles covered or blunted?

SAD Form 1666e-R Previous editions may be used for contract submittals prior to Nov 03. Reference: EM 385-1-1, 3 November 2003 edition.

G-5-2 ATTACHMENT G-5

e. Except for eye splices in the end of wires and for all endless wire rope slings, are all wire ropes used in hoisting, lowering, or pulling loads one continuous piece, free of knots or splices?

f. Do all eye splices have at least 5 full tucks?

g. If used, are wedge sockets fastening attached without attached the dead end of the wire rope to the live rope?

h. Are they free of eyes or splices formed by wire rope clips or knots?

9. Are the following conditions met for chain? (15.C.01-04)

a. Are chains inspected prior to use and weekly thereafter?

b. Do all coupling links or other attachments have rated capacities at least equal to that of the chain.

c. Are makeshift fasteners restricted from use?

10. Are the following conditions met for fiber rope:(15.D.01-07)

a. Are all ropes protected from freezing, excessive heat or corrosive materials?

b. Are all ropes protected from abrasion?

c. Are splices made IAW manufacture’s recommendations?

d. Do all eye splices in manila rope contain at least 3 full tucks and do all short splices contain at least 6 full tucks(3 on each side of the centerline of the splice)?

e. Do all splices in layed synthetic fiber rope contain at least 4 full tucks and do short splices contain at least 8 full tucks ( 4 on each side of the centerline of the splice)?

f. Do the tails of fiber rope splices extend at least 6 rope diameters (for rope 1” diameter or greater) past the last full tuck?

g. Are all eye splices large enough to provide an included angle of not greater than 60* at the splice when the eye is placed over the load or support?

11. Are the following conditions met for all slings:(15.E.01-06)

a. Is protection provided between the sling and sharp surfaces?

b. Do all rope slings have minimum clear length of 40 times the diameter of component ropes between each end fitting or eye splice?

c. Do all braided slings have a minimum clear length of 40 times the diameter of component ropes between each end fitting or eye splice?

d. Do all welded alloy steel chain slings have affixed permanent identification stating diameter, rated load, lift capacity in vertical, choker, basket configuration, and date placed in service?

e. Is each synthetic web sling marked or coded to identify its manufacturer, rated capacities for each type hitch and the type material?

SAD Form 1666e-R Previous editions may be used for contract submittals prior to Nov 03.

G-5-3 ATTACHMENT G-5

12. Are drums, sheaves, and pulley smooth and free of surface defects that may damage rigging? (15.F.01)

13. Is the ratio of the diameter of the rigging and the drum, block sheave or pulley thread diameter such that the rigging will adjust without excessive wear, deformation, or damage? (15F.02)

14. Have all damaged drums, sheaves and pulleys been removed from service?

(15.F.04)

15. Are all connections, fittings, fastenings, and attachments of good quality, proper size and strength, and installed IAW manufacturer’s recommendations?

(15.F.05)

16. Are all shackles and hooks sized properly? (15.F.06 & .07)

17. Are hoisting hooks rated at 10 tons or greater provided with safe handling means? (15.F.07)

18. Do all drums have sufficient rope capacity? (15.F.08)

19. Is the drum end of the rope anchored by a clamp securely attached to the drum in a manner approved by the manufacturer? (15.F.08)

20. Do grooved drums have the correct groove pitch for the diameter of the rope and is the groove depth correct? (15.F.08)

21. Do the flanges on grooved drums project beyond the last layer of rope at a distance of either 2” or twice the diameter of the rope, whichever is greater?

(15.F.08)

22. Do the flanges on ungrooved drums project beyond the last layer of rope a distance of either 2.5” or twice the diameter of the rope, which ever is greater.

23. Are the sheaves compatible with the size of rope used and as specified by the manufacture? (15F.09)

G-5-4 ATTACHMENT G-5

24. Are sheaves properly aligned, lubricated, and in good condition?

(15.F.09)

25. When rope is subject to riding or jumping off a sheave, are sheaves equipped with cablekeepers? 915.F.09)

26. Are eyebolts loaded in the plane of the eye and at angles less than 45* to the horizontal? (15.F.10)

27. Remarks: (Enter actions taken for “no” answers.)

Contractor QC/safety/project manager signature

G-6-1 ATTACHMENT G-6

SAFETY CHECKLIST FOR MOTOR VEHICLES,

TRAILERS AND TRUCKS

1. Are records of safety inspections of all vehicles available? (18.A.02)

2. Are all vehicles to be operated between sunset and sunrise equipped with: (18.A.04)

a. 2 headlights?

b. Taillights and brake lights?

c. Front and back turn signals?

d. 3 emergency flares, reflective markers, or equivalent portable warning devices?

3. Are vehicles, except trailers or semi-trailers having a gross weight of 5000 lbs or less, equipped with service brakes and manually operated parking brakes? (18.A.05)

4. Are service brakes on trailers and semitrailers controlled from the driver’s seat of the prime mover? (18A.05)

5. Does the vehicle have: (18.A.06)

a. An operable speedometer?

b. An operable fuel gage?

c. An operable audible warning device (horn)?

d. A windshield & adequate windshield wiper?

e. An operable defroster and defogging device?

f. An adequate rearview mirror?

g. A cab, cab shield, and other protection to protect the driver from the elements and falling or shifting materials?

h. Non-slip surfaces on steps?

I. A power-operated starting device?

SAD Form 1666d-R Previous editions may be used for contract submittals prior to Nov 03.

G-6-2 ATTACHMENT G-6

6. Is all the glass safety glass and is all broken or cracked glass replace?

(18.A.07)

7. Do trailers meet the following: (18A.08)

a. Are all towing devices adequate for the weight drawn?

b. Are all towing devices properly mounted?

c. Are locking devices or a double safety system provided on every 5th wheel mechanism and tow bar arrangement to prevent accidental separation?

d. Are trailers coupled with safety chains or cables to the towing vehicle?

e. Are trailers equipped with the power brakes equipped with a breakaway device which will lock-up the brakes in the event the trailer separates from the towing vehicle?

8. Are all dump trucks:(18.A.10)

a. Equipped with a holding device to prevent accidental lowering of the body?

b. Equipped with a hoist lever secured to prevent accidental starting or tipping?

c. Equipped with means to determine (from the operator’s position) if the dump box is lowered?

d. Equipped with trip handles for tailgates that allows the operator to be clear?

9. Are all buses, trucks and combination of vehicles with a carrying capacity of 1.5 tons or more, to be operated on public roads equipped with:

(18.A.11)

a. 3 reflective markers?

b. 2 wheel chocks for each vehicle?

c. At least one 2A:10B:C fire extinguisher?

d. At least two properly rated fire extinguishers (for vehicles carrying flammable cargo)?

e. A red flag not less than 1-foot square.

10. Is vehicle exhaust controlled so as not to present a hazard to personnel? (18.A.13)

11. Are all rubber tired motor vehicles equipped with fenders or with mud flaps if the vehicle is not designed for fenders? (18.A.14)

Reference: EM 385-1-1, 3 November 2003 edition

G-6-3 ATTACHMENT G-6

12. Are all vehicles, except buses, equipped with seat belts? (18.B.02)

13. Does all self-propelled construction and industrial equipment have a working reverse signal alarm? (16.B.01)

14. Are all hot surfaces of equipment, including exhaust pipes or other lines, guarded or insulated to prevent injury or fire? (16.B.03)

15. If an off the road vehicle, is it equipped with rollover protective structures? (16.B.12)

16. Remarks: (Enter actions taken for “no” answers)

G-7-1 ATTACHMENT G-7

SAFETY CHECKLIST FOR CRAWLER TRACTORS

AND DOZERS

1. Are initial and daily/shift inspection records available? (16.A.01& .02)

2. Are only qualified operators assigned to operate mechanized equipment? (16.A.04)

3. Are sufficient lights provided for night operations? (16.A.11)

4. Is the unit shut down before refueling? (16.A.14)

5. Does the unit have as a minimum a 5-B:C fire extinguisher? (16.A.34)

6. Is there an effective, working reverse alarm? (16.B.01)

7. Are moving parts, shafts, sprockets, belts, etc., guarded? (16.B.03 ,07, and 13)

8. Is protections against hot surfaces, exhausts, etc., provided? (16.B.03 and .13)

9. Are fuel tanks located in a manner to prevent spills or overflows from running onto engine exhaust or electrical equipment? (16.B.04)

G-7-2 ATTACHMENT G-7

10. Are exhaust discharges directed so they do not endanger person of obstruct operator vision? (16.B.05)

11. Are seat belts provided? (16B.08)

12. Is protection (grills, canopies, screens) provided to shield operator from falling or flying objects? (16.B.10 and .11)

13. Is roll over protection provided? (16.B.12)

14. Remarks: (Enter actions taken for “no” answers)

G-8-1 ATTACHMENT G-8

SAFETY CHECKLIST FOR SCRAPERS, MOTOR GRADERS,

AND OTHER MOBILE EQUIPMENT

Equipment name and number:

Contractor: Subcontractor:

Contractor inspector: Date inspected:

1. Are initial and daily/shift inspection records available? (16.A.01 & .02)

2. Are only qualified operators assigned to operate equipment? (16.A.04)

3. Are sufficient lights provided for night operations? (16.A.11)

4. Does the unit have as a minimum a 5-B:C fire extinguisher? (16.A.26)

5. Is there an effective working reverse alarm? (16.B.01)

6. Is the unit shut down for refueling? (16.A.12)

7. Are moving parts, shafts, sprockets, belts, etc., guarded? (16.B.03, .07 and .13)

8. Is protection against hot surfaces, exhausts, etc., provided? (16.B.03 and .13)

9. Are fuel tanks located in a manner to prevent spills or overflow from running onto engine exhaust or electrical equipment? (16.B.04)

10. Are exhaust discharges directed so they do not endanger persons or obstruct operator vision? (16.B.05)

SAD Form 1666f-R Previous editions may be used for contract submittals prior to Nov 03.

G-8-2 ATTACHMENT G-8

11. Are seat belts provided for each person required to ride on the equipment? (16.B.08)

12. Is protection (grills, canopies, screens) provided to shield operators from falling or flying objects? (16.B.10 and .11)

13. Is roll over protection provided (ROPS)? (16.B.12)

14. Is a safe means of access to the cab provided (steps, grab bars, non-slip surfaces)? (16.B.03)_

15. Are adequate head and taillights provided? (16.A.07)

16. Have brakes been tested and found satisfactory? (16.A.07)

17. Does the unit have an emergency brake which will automatically stop the equipment upon brake failure? Is this system manually operable from the drivers position? (16.A.07)

18. Is all equipment with windshields equipped with powered wipers and defogging or defrosting system? (16.A.07)

19. Are all vehicles that will be parked or moving slower than normal traffic on haul roads equipped with a yellow flashing light or flasher visible from all directions? (16.A.13)

20. Is the slow moving emblem used on all vehicles which by design move at 25 MPH or less on public roads? (08A.04)

21. Have air tanks been tested and certified? (20.A.01)

22. Is an air pressure gage in working condition installed on the unit?

(20.A.12)

23. Does the air tank have an accessible drain valve? (20.B.17)

Page 2 0f 3

G-8-3 ATTACHMENT G-8

24. Remarks: (Enter action taken for all “no” answers)

Contractor QC/safety officer/project manager

G-9-1 ATTACHMENT G-9

SAFETY CHECKLIST FOR MATERIAL HOISTS

Contract Inspector:

1. Prior to initial use on any USACE project, and at least monthly thereafter, is a periodic inspection conducted by a qualified person?

(16.K.05)

a. Are periodic inspections conduction IAW manufacturer’s specification?

b. At a minimum are sheaves, racks, pinions, guy ties, connections, miscellaneous clamps, braces, and similar parts?

c. Is the GDA notified at least 24 hours prior to any inspections?

d. Are pre-operational inspections conducted prior to every operation

(shift) of the hoist?

3. Are all hoist towers, masts, guys or braces, counterweights, drive machinery supports, sheave supports, platforms, supporting structures, and accessories designed by a licensed engineer? (16.K.02)

4. Is a copy of the hoist-operating manual available? (16.K.04)

5. Do all floors and platforms have slip-resistant surfaces? (16.K.08)

6. Are landings and runways adequately barricaded and is overhead protection provided where needed? (16.K.08)

7. Are hoisting ropes installed IAW manufacturer’s instructions?

(16.K.10)

a. Are there at least three (3) full wraps of cable on the drums of the hoist at all times?

b. Does the rope or crane manufacturer specify the drum end of the rope anchored to the drum by an arrangement?

c. Are personnel prohibited from riding on material hoists or other hoisting equipment?

8. Are operating rules posted at the hoist operator’s station? (16.K.14)

SAD Form 1666g-R Previous editions may be used for contract submittals prior to Nov 03.

Reference: EM 385-1-1, 3 November 2003 edition. Page 1 of 2

G-9-2 ATTACHMENT G-9

9. Are air-powered hoists connected to an air supply of sufficient capacity and pressure to safely operate the hoist? (16.K.15)

10. Are pneumatic hoses secured by some positive means to prevent accidental disconnection? (16.K.15)

11. Remarks: (Enter actions taken for all “no” answers.)

SAD Form 1666g-R Previous editions may be used for contract submittals prior to Nov 03.

Page 2 of 2-

G-10-1 ATTACHMENT G-10

SAFETY CHECKLIST FOR EARTH DRILLING EQUIPMENT

Contract # and title:

Equipment name & number:

Contractor: Subcontractor:

Contractor inspector: Date inspected:

Yes No N/A

1. Is a copy of the manual for all drilling equipment available? (16.M.01)

2. Have all overhead electrical hazards and potential ground hazards been identified in a site layout plan and addressed in an activity hazard analysis? (16.M.02)

3. Are MSDSs for all drilling fluids available?

(16.M.05)

4. Does the drilling equipment have 2 easily accessible emergency shut down devices (one for the operator and one for the helper)? (16.M.06)

5. Is the equipment posted with a warning of electrical hazards? (16.M.06)

6. Is there a spotter or an electrical proximity warning device available to ensure safe distances from power lines are maintained?

(16.M.06)

7. Remarks: (Enter actions taken for “no” answers)

Contractor inspector signature

Contractor QC/safety officer/project manager

SAD Form 1666h-R Previous editions may be used for contracts Mar 97 referencing the 1992 edition of EM 385-1-1.

SHEET OF

I certify that the above submitted items have been reviewed in detail and are correct and in strict conformance with the contract drawings and specifications except as other wise stated.

CHECK ONE:

THIS IS A NEW TRANSMITTAL

THIS IS A RESUBMITTAL OF

TRANSMITTAL

DATE

REMARKS

CONTRACT REFERENCE

DOCUMENT

SPECIFICATION SEC. NO. (Cover only one section with each transmittal)

TO: FROM:

PROJECT TITLE AND LOCATION

CONTRACT NO.

ENCLOSURES RETURNED (List by Item No.)

TRANSMITTAL OF SHOP DRAWINGS, EQUIPMENT DATA, MATERIAL SAMPLES, OR

MANUFACTURER'S CERTIFICATES OF COMPLIANCE

(Read instructions on the reverse side prior to initiating this form)

SECTION I - REQUEST FOR APPROVAL OF THE FOLLOWING ITEMS (This section will be initiated by the contractor)

TRANSMITTAL NO.

NAME, TITLE AND SIGNATURE OF APPROVING AUTHORITY DATE

SECTION II - APPROVAL ACTION

ITEM

NO.

a.

DESCRIPTION OF ITEM SUBMITTED

(Type size, model number/etc.)

b.

MFG OR CONTR.

CAT., CURVE

DRAWING OR

BROCHURE NO.

(See instruction no. 8) c.

NO.

OF

COPIES

d.

SPEC.

PARA. NO.

e.

DRAWING

SHEET NO.

f.

FOR

CONTRACTOR

USE CODE

g.

VARIATION

(See instruction No. 6) h.

FOR

CE

USE

CODE

i.

NAME AND SIGNATURE OF CONTRACTOR

ENG FORM 4025, May 91…