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ENSAFE PRE-DRILLING/EXCAVATION UTILITY CHECKLIST(COMPLETE IN ADDITION TO THE SWAP) Site Name &Address: EnSafe Project Number & Manager: Proposed Date of Field Work & Duration: Project Manager Signature AFTER fieldwork has been completed. (A)=To be accomplished during planning stages (B)=To be accomplished onsite before fieldwork activities UNDERGROUND UTILITIES PUBLIC AND PRIVATE PROPERTY REQUIREMENTS YES NO 1(A). Has the "State-Specific One Call" been notified to mark the locations of all underground ❑ ❑ utilities? Update One-Cali if Fieldwork is Extended Past 2 Weeks After Inquiry. 2(A). One-Call Ticket Info. Date Ca//ed: One-CallPhone#: (REQUIRED BYLAW). Ticket Number: Beginning& Expiration Date/Time: Entities to be contacted separate/y.- 3(A&B). Have facility (and other relevant) personnel been interviewed and asked to provide copies ❑ ❑ of all available facility diagrams and drawings about underground utilities near the excavation area? 4(B). Has an onsite walk-through been accomplished to identify surface indicators of utilities? ❑ ❑ S(B). Have the types/positions of underground utilities been marked on the surface by one-call ❑ ❑ and/or the facility? Do the field personnel understand how these utilities traverse underground? 6(A&B). Have the locations of utilities been inserted on the work area drawing(s)? ❑ ❑ 7(B). Has all available information concerning the type/location/depth of known underground utilities been given to the responsible supervisor or contractor at the work site for review and ❑ ❑ possible offset/relocation? 8(B). Have suitable cable and pipe locating devices (PM/Qualified Safety Review approval) ❑ ❑ been used to confirm position of the utilities? 9(B). Have appropriate tools (hand auger and/or equivalent technology) been used to dig trial holes (minimum depth of 4 FEET below ground surface AND ideally to include the minimum diameter of downhole sampling tool, including any surficial materials) to visually identify position/depth of the underground utilities, or to determine that utilities are not ❑ ❑ present within the test location? Depending on regional subsurface (Depth of Frost in NE part of USA) conditions, unground utilities may be buried deeper than 4 feet. All modifications regarding assumed depth shall be documented in the Field Notes/Concerns section on the next page. Z 10(B). During excavation (at all times), a watch is kept for evidence of cables, pipes, or other >; underground utilities not previously identified. Q J 0 11(B). If heavy equipment is required to cross an area where underground utilities are known to be W present, the cross points are kept to a minimum and are clearly marked. — Please refer to the back of this form for explanations and tips on how to answer the questions listed above. Also use the back of this checklist for comments/concerns to any of these questions and/or contact a Qualified Safety Reviewer (listed on the EnSafe Intranet) for the specific State/Region that fieldwork is performed. — A Qualified Safety Reviewer MUST be consulted and approve this site-specific form BEFORE fieldwork may commence if the answer to ANY Ouestion on the checklist is NO). Expedited approval (Telephone/Email/In Person) is possible prior to starting work operations, but advanced noticed is preferred to allow the reviewer time to look at maps/drawings of the site and all other relevant documents. Checklist Submitted By: Qualified Safety Review (If Needed): Name: Name: Signature: Signature: Date: Date: Revised March 27, 2017