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WESTERN PUMP <br /> Petroleum & Lubrication Equipment Specialists <br /> Other (describe): <br /> B. Identify the type of fall prevention measure to be utilized for each hazard , by placing the appropriate <br /> number in the " Measure" column . Options include: <br /> 1 . Personal Fall Arrest System <br /> 2. Fall Restraint <br /> 3, Work Positioning <br /> 4, Guardrail System <br /> 5. Covers <br /> 6, Controlled Access Zone <br /> 7. Warning Line System <br /> 8. Safety Monitoring System <br /> Hazard Description Measure (#) <br /> Roof <br /> Leading edge <br /> Sky light <br /> Balcony <br /> Elevator shaft <br /> Floor opening (greater than 12") <br /> Wall opening (greater than 18") <br /> Excavation <br /> Utility (vault, man hole, etc.) <br /> Other (describe) : <br /> Other (describe) : <br /> Fall Protection Project Hazard Assessment Checklist (continued) <br /> C. If using PFAS, including a Self Retracting Lanyard , calculate the total fall clearance required: <br /> (Length of Lanyard + Deceleration Distance + Height of Worker + Safety Factor) = Total Fall Clearance <br /> Notes: <br /> I. If total Fall Clearance Required exceeds the actual fall distance, the worker will impact the lowerievel <br /> prior to being arrested, and an alternative method must be identified. <br /> 3235 "F" Street, San Diego, CA 92102-3315 * 619-239-9988 Fax 619-239-9925 <br /> www. westernpump . com <br /> California Contractor's License #673853 <br /> California Certified Small Business #33547 <br />