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BLAINE"r Daily Tailgate Safety Meeting Checklist& <br /> TECli�SERV CES Hazard Assessment and Mitigation Form TGSM <br /> Site AddrE ss: 1.1 3 s° � ! Date: <br /> Check-in Nith site representative completed? WYes ❑N/A <br /> Is fuel delivery scheduled for today? ❑Yes R1 No ❑NIA <br /> Emergency pump cut-off switch located? <br /> M Yes ❑N/A <br /> First aid Vit located and confirmed ready-to-use? ®Yes <br /> Fire extinguisher located and confirmed ready-to-use? 0Yes <br /> Eye wash located and confirmed ready-to-use? ( Yes <br /> Emergency Services information located&reviewed? [ Yes <br /> Hospital map&route located and reviewed? ®Yes <br /> HASP Special Hazard Notice section reviewed? ®Yes <br /> Site Status confirmed or amended, dated and initiated? NYes <br /> Emergency Response procedures reviewed with all work crew members? ®Yes <br /> :.ompliance Roster signed by all work crew members? Yes <br /> Site walk has-been performed to locate wells and identify additional hazards? Yes <br /> Job Safetj Analysis(JSA)for each task located&reviewed by all work crew members? ®Yes <br /> Work Area Plans reviewed for suitability and effectiveness given current site conditions? D9 Yes []NIA <br /> Traffic Control Plans reviewed for suitability given current road,traffic&weather conditions? ❑Yes NIA <br /> • In the space below,note unaddressed hazards and conditions that might compromise compliance with Approved <br /> Pm;edures and/or JSA's or impede the safe and proper execution of the Work Plan,Work Area Plan(s)and/or Traffic <br /> Cortrol Plan(s), <br /> • Report unaddressed hazards and adverse conditions to the Project Manager during Pre-Start Call-in and as hazards are <br /> idertified orconditions change throughout the workday, <br /> • DO NOT COMMENCE OR RESTART WORK until PM has been notified and mitigation measures approved. <br /> Time Hazard or Adverse Condition PAR Hazard Control Measure <br /> Initials <br /> Site representative briefed on planned work activities and Work Area Plans? Yes [J N/A <br /> Job Clearance Form completed? Yes <br /> Pre-Start Call-In completed and approval to start work received from Project Manager? ( Yes <br /> Printed Name Signature Time <br /> 075 <br />