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Project Name:Start Date: <br />Project #:End Date: <br />DigSafe 811 notified 48-72 hrs. in advance of work? <br />Ticket Expiration Date: <br />List addt'l. utilities requiring notification not included in DigSafe811 Notice: <br />Marking type:Paint Pin Flags/Stakes Other:None <br />Client provided maps/drawings (Y/N)?Maps/drawings not provided (Y/N)? <br />Client Clearance (Y/N)?Name(s)/Affiliation(s): <br />Name(s)/Affiliation(s): <br />Specific subsurface feature types and depths provided by person interviewed (Y/N)? <br />Details provided: <br />Site Inspected (Y/N)? (document on Pg. 2.) Photo Document Marked Utilities & Structures <br />Public records/Client Dwgs/As-Builts (Y/N)? Type: <br />List private locator tools used:Radio Freq. Detection Electromagnetic GPR <br />Metal Detector Acoustic Pipe Locator Downhole sonde Other: <br />Soft Dig Methods used (Y/N)?Hand auger Probing Hand tools (shovel/rake) <br />Air knife Hydro Knife Potholing/Vacuum extraction <br />Other soft dig tools used (Y/N)? If Yes, list here: <br />Utility markings valid for 15 days. Initiate clearance renewal 5 days prior to expiration for ongoing work <br />PRE-FIELD WORK REQUIREMENTS <br />DigSafe Ticket #: <br />State Utility Laws: www.commongroundalliance.com/map <br />Ticket(s) Attached(Y/N)? <br />THIS FORM MUST BE ENTIRELY COMPLETED PRIOR TO BEGINNING ANY INTRUSIVE WORK <br />Forward Landfill Manteca, CA <br />30225884 <br />List utility owners notified via DigSafe 811 & response status: <br />Review task details w/ private utility location subcontractor. ID work areas, clearance equipment needed, <br />depth of clearance needed, types of features, utilities, anticipated/known/unknown. Verify DigSafe 811 <br />markings to confirm public utility clearance. <br />Private Utility Locator Name, if used:AUS onsite meeting (Y/N)? <br />FIELD WORK REQUIREMENTS <br />This portion of the checklist must be completed on site. AUS staff must have a minimum of one year of <br />field experience in identifying utilities to complete the checklist. Field staff will review the completed <br />checklist with PM or designee prior to beginning intrusive work. <br />Heavy equipment/mechanized intrusive work w/in the Arcadis Tolerance Zone (utility or structure present <br />within 30-in. of point of work) REQUIRES pre-approval by Corporate H&S prior to working at all such <br />locations. STOP WORK if the Arcadis Tolerance Zone work has not been approved. <br />List work type & locations for utility location and clearance as applicable to this checklist: <br /> 3 Reliable Lines of Evidence are REQUIRED for EACH INTRUSIVE LOCATION prior to starting any <br />subsurface intrusive work. Check corresponding boxes below to document utility clearance efforts. <br />OneCall/DigSafe 811 Public Utility Locate (required by State law for subsurface work) <br />811 is only reliable as a Line of Evidence when working in/adjacent to a public ROW or easement. <br />Interviews (Y/N)?