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AECOM Americas Underground Utilities & Subsurface Installation Clearance Checklist S3AM-331-FM1 Location: Project#: Date&Time: Manager: Contractor(if applicable): Weather: Client: Inspector: Notes: Part 1 Part 1 and Part 2 shall be completed prior to any intrusive subsurface work. DO NOT DISTURB GROUND if a "No"or "N/A"answer to any of the Part 1 questions has not been initialed as authorized by the AECOM Manager. Any variance from these procedures requires approval of the Vice President of the applicable business group. Yes No N/A I. Permits and Access Agreements 1. Have all appropriate permits and agreements been identified and obtained (e.g. client, ❑ ❑ ❑ drilling,encroachment,working near railroads, etc.)? 2. Have all client requirements been identified and obtained? ❑ ❑ ❑ 3. If working off-site is (are)site access agreement(s)executed? ❑ ❑ ❑ II. General Health and Safety 1. Has a Health and Safety Plan (HASP)been prepared for AECOM employees? ❑ ❑ ❑ 2. Do on-site personnel have required-level PPE? ❑ ❑ ❑ 3. Do on-site personnel have required-level of training? ❑ ❑ ❑ 4. Is appropriate monitoring equipment as specified in HASP/THAs available at each clearance ❑ ❑ ❑ location? 5. Has the field screening equipment been calibrated as required by the HASP? ❑ ❑ ❑ 6. Are calibration gases available at the site? ❑ ❑ ❑ III. Identification and Mapping of Utility and Subsurface Structures 1. Is a Site Plan showing proposed subsurface locations and utility locations attached to this ❑ ❑ ❑ check list? 2. Have above/below ground utilities&subsurface installations been investigated (Part 2 of this ❑ ❑ ❑ form)? 3. Have all Federal/State/Provincial/Territorial and other"One Call"providers marked their facilities or otherwise notified they do not have any facilities near the proposed ❑ ❑ ❑ subsurface/intrusive locations? 4. Have Federal/State/Provincial/Territorial or other"One Call"providers identified what utilities and underground structures are not included in their provider system (e.g. underground ❑ ❑ ❑ structures)? 5. As noted in the exception at the bottom of Section VI of this checklist, has a utility locating contractor performed geophysical and/or other surveys of the proposed subsurface/intrusive ❑ ❑ ❑ locations? Underground Utilities&Subsurface Installations Clearance Checklist(SMM-331-FM1) Revision 1 September 30,2020 PRINTED COPIES ARE UNCONTROLLED. CONTROLLED COPY IS AVAILABLE ON COMPANY INTRANET. Page 1 of 4