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EXCAVATION PERMI . SIMPLOT - LATHROP Excavation Collapse& Entry Controls Will workers be required to enter the ❑ Yes } Proceed to Rem A excavation(s)? { ( No } Proceed to Item c A: Will the excavation(s)be greater ❑ Yes } Proceed to Rem B than 4 feet deep? ❑ No } Proceed to Rem C B: A safe means of entry will be ❑ The use of secured ladders-at least one per 25 foot section of trench achieved via(must identify one): ❑ The following alternative safe means: Prevention of collapse will be ❑ The use of shoring achieved via(must identify at least ❑ The use of sloping of all sides required one): ❑ The use of benching of all sides required ❑ The use of shielding of all sides required Entry must be controlled using a Confined Space Entry Permit(if ladders or ❑ Atmosphere testing, rescue provisions and an attendant are required for entry other special equipment is necessary to enter into the excavation. the excavation) C: Additional details as applicable(about type of Liu rr%.t. shoring,method of placement/removal, sloping/bench dimensions,access details,etc:) Section 3-Permit Request: This acknowledgement signifies a formal request to commence excavation work As the person requesting this permit,I hereby certify that: • 1 am competent to coordinate this excavation work in accordance with the Hazard Assessment details; • I shall Implement all planned and necessary controls to ensure safe excavation access and work methods;and • 1 shall monitor the excavation/work hazards and control methods throughout the excavation work. Name: ,j a, V-1" G k Signatur6: I� Date: J f (3 8 Section 4-Authorization: EngineeringMM n//a�ger,Verfies�'cation of underground utilities and pi n d th t the utile locate has been Completed,if required): Name: ylaw'11 /h•n«s Signature: oXvr� Date: '�lcd/l P Environmental Manager and Safety&Security Manager(Verifies t t the procedures,control measures and precautions appropriate for the safe access and/or execution of work involving this excavation(s)have been Identified and the persons responsible for the work understand the requirements)Both signatures are required. Name: Signature- Date: Name: N'�O fK l,.• f i w r ion- Signature: ='`�r-��!K -' Date: I Valid Until: This Authorization is valid until the following occurs,or the date shown: Date: -- _-- Version 3-Page 2 of 2 649.2018