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<br />Revised 8/2021 <br /> <br />Excavation/Trench Inspection and Entry Authorization Form <br />*This form will be completed by the Competent Person daily (at a minimum) or when site conditions change. The completion <br />of this form is mandatory prior to work in any excavations or trenches 4’ in depth or greater. Once work has been completed <br />or at the end of the day, this form must be returned to the Safety Officer or Designated Site Supervisor. <br /> <br />PROJECT SUPERVISOR: PROJECT NUMBER: <br />COMPETENT PERSON: LOCATION/ZONE: <br />DATE: TIME: NUMBER OF CREW MEMBERS: <br />Dimensions Depth= Min. Max. Soil Type Manual Test Measurement <br />Top= Width Length Solid Rock Type B Penetrometer <br />Bottom = Width Length Type A Type C Thumb Penetration <br />HAZARDOUS CONDITIONS* (Visual Checks) Yes No PERIMETER CONSIDERATIONS Yes No n/a <br />Saturated soil/standing or seeping water? Spoils located at least 2’ away from edge? <br />Bulging walls? Materials located at least 2’ away from edge? <br />Rapid drying / shrinkage? Class 1, 2, or 3 perimeter protections in place? <br />Vibration from equipment / traffic? Backhoe located at end of trench? <br />Cracked or fissured walls? Spotter working with the backhoe? <br />Undercutting? Exposed to the general public? <br />Floor heaving? <br />Super imposed loads? LADDER/EGRESS LOCATION Yes No n/a <br />Exposed utilities? Located within protected area? <br />Atmospheric testing required? Located within 25 feet of safe travel? <br /> Oxygen content is between 19.5% and 21%. <br /> <br /> Extends 36” above landing and secured in place? <br />Structures adjacent to trench? Maximum ramp angle without cleats 25°? <br />Trees or roots in the work area? <br />*If the hazards listed above result in a fall hazard or confined space, a corresponding Site-Specific Fall Protection and Prevention Plan or <br />Confined Space Plan must be developed and accepted before work can commence. <br />SHORING Yes No COLOR CODE FOR UTILITY MARKING based on ANSI Z-53.1 <br />Manufacturer tabulated data sheets on site? PROPOSED EXCAVATION WHITE <br />Shoring inspected for defects/damage? ELECTRIC POWER LINES, CONDUITS, LIGHTING CABLES RED <br />Trench shield in use? POTABLE WATER BLUE <br />Speed shores in use? GAS, STEAM, CONDENSATE, OIL COMPRESSED AIR YELLOW <br />Speed shores pumped to design pressure? TELECOMMUNICATIONS, ALARM OR SIGNAL LINE ORANGE <br />Plywood or sheeting to be used? TEMPORARY SURVERY MARKINGS PINK <br />SLOPING SEWER AND STORM DRAINS GREEN <br />Type A soils at a minimum of 3/4:1 (53°)? RECLAIMED WATER, IRRIGATION, CHILLED LINES PURPLE <br />Type B soils at a minimum of 1:1 (45°)? OTHER LIGHT BLUE <br />Type C soils at a minimum of 1 1/2:1 (34°)? EXCAVATION/TRENCH COMPETENT PERSON SIGNATURE <br /> <br />X <br />BENCHING <br />Type A and B soils benched? (NO Type C) <br />Max height of Type B soil bench 4’? <br /> <br />Names of personnel authorized to enter the excavation/trench: <br /> <br /> <br /> <br />