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BROWN AND Attachment C—Site Safety and Health Plan CALDWELLSafety Plan Implementation Checklist L Project Name Project Location (city and state) Date Name of Site Safety Coordinator Weather Conditions Project Number LBC Staff Present Name Office Indicate the status of each of the following: 1. Is a copy of the Site Safety and Health Plan (SSHP) on site? ❑ YES ❑ NO ❑ N/A 2. Is the personal protective equipment required by the SSHP available and being ❑ YES ❑ NO ❑ NIA used correctly? 3. Have the work zones been delineated? ❑ YES ❑ NO ❑ NIA 4. Has a decontamination station been set up as required by the SSHP? ❑ YES ❑ NO ❑ NIA 5. Are the decontamination procedures being followed? ❑ YES ❑ NO [•] NIA *1. 6. Is access to the exclusion zone being controlled? ❑ YES ❑ NO [:1 NIA. 7. Has the he site activities briefingand tailgate safety meeting been provided? E] YES ❑ NO ❑ NIA 8. Is the list of emergency telephone numbers posted at the support zone? ❑ YES ❑ NO ❑ NIA L9. Are directions to nearest emergency medical assistance posted at support zone? ❑.YES ❑ NO ❑ NIA 10. Is emergency equipment available and functional, as required by the SSHP? ❑ YES ❑ NO ❑ NIA UE] YE11. Has the nearest toilet facility been identified or a portable facility been setup? EI-YES ❑ NO ❑ NIA 12. Has an adequate supply of drinking water been provided? S El N6 N/A 13. Has water for decontamination been provided? ❑ YES ❑ NO ❑ NIA 14. Have the instruments for environmental and exposure monitoring been calibrated and set up as required by the SSHP? ❑ YES , ❑ NO ❑ NIA . 15. Are the instruments being used properly and periodically checked during the shift for battery charge status? ❑ YES ❑ NO ❑ NIA L hes and excavations been clear! marked? ❑ YES ❑ NO N/A 16. Have the trenches Y 17. Have trenches and excavations been shored or sloped as required by soil type tom' and work activities? ❑ YES ❑ NO ❑ NIA 18. Are dust suppression measures being used? ❑ YES ❑ NO ❑ NIA ' 19. Is food and tobacco consumption being restricted to the support zone? ❑YES ❑ NO [—] NIA 20. Has a confined space been identified as part of this project? ❑ YES ❑ NO ❑ NIA 21. Are the confined space entry procedures being correctly implemented? ❑YES ❑ NO ❑ NIA 22. Has the work/rest cycle for the shift been established? ❑ YES ❑ NO ❑ NIA TIME ON (minutes): TIME OFF (minutes): 23. Has a shaded rest area been set up in the support zone? ❑ YES ❑ NO ❑ NIA { NOTE: Place completed form in project file. HS-18 REV. 06198