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19 c Afchment. C—Site ScRety & Health Plan r� Safety Pian Implementation Checklist Projea Name Project Location (city and state) Date Name of Site Safety Officer Weather Conditions Project Number SC Slaif Present Name Office Indicate the status of each of the iollow,ng. 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 ❑ N/A used correctly? 3. Have the work zones been delineated? ❑ YES ❑ NO ❑ N/A 4. Has a decontamination station been set up as required by the SSHP? ❑ YES ❑ NO ❑ WA s. Are the decontamination procedures being followed? ❑ YES ❑ NO ❑ N/A 6. Is access to the exclusion zone being controlled? ❑ YES ❑ NO ❑ N/A 7. Has the site activities briefing and tailgate safety mewing been provided? ❑ YES ❑ NO ❑ N/A e. Is the list of emergency telephone numbers posted at the support zone? ❑ YES ❑ NO ❑ N/A 9. Are directions to nearest emergency medical assistance posted at the support zone? ❑ YES ❑ NO ❑ WA 1o. Is emergency equipment available and functional, as required by the SSHP? ❑ YES ❑ NO ❑ NIA 11. Has the nearest toilet facility leen identified or a portable facility been set up? ❑ YES ❑ NO ❑ N/A 12. Has an adequate supply of drinking water been provided? ❑ YES ❑ NO ❑ WA 13. Has water for decontamination been provided? ❑ YES ❑ NO ❑ WA 14. Have the instruments for environmental and exposure monitoring been calibrated ❑ YES ❑ NO ❑ WA and set up as required by the SSHP? 1 S. Are the instruments being used properly and periodically checked during the ❑ YES ❑ NO ❑ N/A shift for battery charge status? 16. Have trenches and excavations been clearly marked? ❑ YES ❑ NO ❑ WA 17. Have trenches and excavations been shored or sloped as required by soil ❑ YES ❑ NO ❑ N/A type and work activities? 13. Are dust suppression measures being used? C3YES C3NO ❑ N/A 19. Is food and tobacco consumption being restricted to the support zone? ❑ YES ❑ NO 7-1 N/A 2o. Has a confined space been identified as part of this project? ❑ YES ❑ NO ❑ N/A 21. Are the confined space entry procedures being correctly implemented? ❑ YES ❑ NO ❑ N/A 22. Has the worWrest cycle for the shift been established? ❑ YES ❑ NO ❑ WA TIME ON (minutes): TVAE OFF (minutes):. 23. Has a shaded rest area been set up in the support zone? ❑ YES ❑ NO ❑ WA sepN,,,,acuowtu Place completed form in project file. Mws�*".sY