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Subsurface Utility Clearance Management Program 2.9 Appendix C - Roux Subsurface Utility Clearance Checklist Roux Subsurface Utility Clearance Checklist Date of Revision— 12/3/14 Work site set-up and work execution o Q COMMENTS INCLUDING JUSTIFICATION IF ACTIVITY Z Z RESPONSE IS NO OR NOT APPLICABLE Daily site safety meeting conducted, SPSAs performed, JSAs reviewed, appropriate work permits obtained. HASP is available and reviewed by site workers/visitors. Subsurface Utility Clearance Procedure has been reviewed with all site workers. Work area secured; traffic control established as needed. Emergency shut-off switch located. Fire extinguishers/ other safety equipment available as needed. Utility mark-outs(public/private)clear and visible. Provide Excavator's Stake-Out Reference Number/ Request Date/Time. Tolerance zone work identified. Work execution plan reviewed and adhered to(ground disturbance methods, clearance depths, any special utility protection requirements,or any other execution requirements;especially for Tolerance Zone work). Verbal endorsement received from Roux PM for any required field deviations to work execution plan. Key reminders for execution: The Subsurface Utility Clearance Protocol should be referenced to determine all requirements while executing subsurface work. The bullet points below are intended as general reminders only and should not be solely relied upon. • Tolerance zone is defined as two feet plus half of the diameter or half of the greatest dimension (for elliptical sewers, duct banks and other non-cylindrical utilities)of a utility and two feet from the outside of any subsurface structure. • Install Pre-Clearance exploratory test holes(e.g., hand-dug test holes or vacuum excavation) must be performed for the first five feet below land surface (BLS) at each location prior to conducting mechanized intrusive activities. The size of the pre-clearance exploratory test hole should be at a minimum twice the diameter of any downhole tool or boring device. (Note: Pre-clearance exploratory test holes should be defined in the SOW/proposal provided to the client to prevent project delays and to allow adequate time for PM and PP to evaluate alternative approaches for the project. Alternate approaches will need to be pre-approved by the OM. • For excavations, all utilities need to be marked and then exposed by hand following the protocols in this program. Pre-clearing for excavations may be performed by the "moat"technique (i.e., soft 1/2019 Corporate Health and Safety Management Program I ROUX 11