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i # ATTACHMENT 4 PRE-DRILLINGIEXCAVATION CHECKLIST AND UTILITY CLEARANCE LOG PROJECT: LOCATION: DATE: UTILITY LOCATOR: UTILITY LOCATOR PHONE#: BATE OF LOCATOR REQUEST: LOCATOR CALL REFERENCE#: Instructions: This checklist is to be completed by STANTEC personnel prior to initiation of freid activities as a safety measure to insure that all underground utility lines,other underground structures and above-ground power lines are clearly marked in'the area selected for boring or excavation. f DRILLING OR EXCAVATION WORK MAY NOT PROCEED UNTIL ALL UTILITY SERVICES LISTED IN SECTION 8.0 OF THIS HASP HAVE BEEN CONTACTED AND THIS CHECKLIST HAS BEEN COMPLETED. 1F ANY OF THE QUESTIONS!ANSWERED BELOW ARE ANSWERED"NO",THEN PROJECT MANAGER MUST BE CONTACTED AND CONCERNSIISSUES DISCUSSED. Document the reason for a"NO"answer omthe back of this form. Type of Utilities and Structures Not Present How Marked(Flags, paint on pavement,wooden stakes,etc.) Present Petroleum product line a f � Septic tank/drain field + Other YES NO PRE-MOBILIZATION Is a scaled site plan, map or drawinq showing the proposed borehole locations attached to this form? Does each borehole location allow for clear entry and exit, adequate workspace, and a clear path for raising the mast and operating the drill rig and all support equipment?Ensure 20 feet of clearande distance between the mast and electrical lines t (STANTEC H&S Policy and 29 CFR 1926.550). Check with the power utility company. Are all of the proposed borehole locations and associated areas of pavement cutting at least 10 feet from any subsurface or above-ground utilities shown on client's building plans? STANTEC PM check here El if plans not provided by client(therefore not applicable to this job). Are all of the proposed borehole locations and associated areas of pavement cutting at least 10 feet from any subsurface or above-ground utilities shown on public right-of-way street improvement or other public property plan or site map? PM check here 0 if not applicable to this ob. Has the Site Representative,familiar with the site,such as a construction manager,:indicated no knowledge of any subsurface or above-ground utilities within 10 feet of the proposed borehole locations?, Is the Site Representative qualified to make such i a determination? Are all of the proposed borehole locations and associated areas of pavement cutting at least 10 feet from any subsurface utilities identified during a geophysical survey?Applicable: Yes I No t Have all Utility Locating Service providers notified by the public line locator marked out their facilities in the vicinity of the �t. borehole locations or otherwise notified us that they do not have any facilities near the proposed borehole locations? Are all proposed borehole locations and associated areas of pavement cutting at least 10 feet from a visual line connecting two similar looking manhole covers? Are all proposed borehole locations and associated areas of pavement cutting at least 10 feet from a visual line perpendicular to the street from the water, as and electrical meters? Are all proposed boring locations and associated areas of pavement cutting;clear of pavement joints, curbs,crash posts,or other engineered structures? Does the pavement lack signs of previous excavation(e.g. no pavement subsidence, no differences in pavement texture or + relief, no pavement atchin ? If there are signs,determine the purpose ofithe revious excavation and act accordingly. Before drilling have you hand dug/used a water jet VacTron unit/tile probe/etc., to dig a hole 5 feet below grade if possible, and is the diameter of the hole at least 2 inches greater than the outer diameter of the drilling auger? Does the soil you encountered in the hand-dug hole appear to be native material(i.e.free of clean gravel,clean sand, aqqreqate base[gravelly sand with—10%fines], or other non-native looking material)? f �f Have you made sure that you have identified all the expected utilities or have made sure that you can explain any missing f utilities? Have the above concerns been discussed with the STANTEC Project Manager? Yes' ! No Have the above concerns been discussed with the client? Yes ! No Have you made a reasonable effort to resolve the above issues? Yes ! No Approval to proceed provided by: Client Representative Name Title and Date: 444 Approval to proceed provided by: STANTEC Representative Name Title and Date: STANTEC Field Technician Name: Title and Date: STANTEC Consulting Corporation Attachment 4 :� ,l