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REMEDIATION MANAGEMENT-AUTHORIZATION TO WORK <br /> i <br /> 2. <br /> 4. 4S. . <br /> 5 -- _- <br /> 6. 6. <br /> ` `- t� <br /> 1. Hydrogen Sulfule 2. Benzena3. ElDiesel j 4. ydrocarbon 5. ❑Acid 6.❑Lead <br /> 7. Carbon Monoxide _ 8. ❑_Asbestos ❑Caustic 10. Gasoline II. Heavy Metals <br /> 12. NORMS l3. ❑Other <br /> ❑ <br /> 19. ❑ Radiation 20,K Electric 121.E Pneumatic 22. ❑ Thermal-Steam <br /> 23. ❑Hydraulic 24...LJ Pressure 25. Mechanical 126. ❑Fluids&Gases <br /> 27. ❑ Gravitational {28. ❑ Other: <br /> 34. Walking 1 Working Surfaces - 35. Trak 3b. ©Working at Heights 37. Pinch Points <br /> 38. ❑Weather 39. ❑Noise 140. ❑Grinding 1 41. ❑Heavy equipment 142. a Sharp Edges <br /> 43. ❑Hot Work 44. ❑Security 45. Congested Area 46.❑Overhead Work <br /> 47. ❑Body Position 48. ❑Static Posture 49. ❑Wind 50.,N Rotating Equipment 51. ❑Lifting <br /> 52. &Housekeeping 53. ❑Spills 54.❑Underground Utility 55. Ej Slopes and Terrain <br /> 56. ❑Confined Space 57. ❑Vibration 58.❑Ground Disturbance 59. ❑Rigging <br /> 60. ❑Vehicle Safety-Driving 61,[]Repetitive Motion 62. ❑ Caniainer/Drum Labels <br /> 63. ❑Waste 64. ❑HeadCold Stress 65. Hand&Power Tools 66. ❑Fitness to Work <br /> 67. ❑Open Pipe _ 68. ❑_Boom Swing 69.❑Lighting 70. C-]Exposureto poisonous plants I animals I bugs <br /> 71. ❑OverheadElectrical _ - 72. ❑Auger/DrillStem 73. ❑p Other: <br /> 79. Sae Glasses 80. ❑ Goggles 81. Face Shield 82.�]Ear Plu s 83. Re ective Ves! , <br /> i 84.' Hard Hat 85. ❑ Escape Palo 86. - Sa ety Tos Shoes 87.❑Ear Mue's 88. ❑Respirator: <br /> 89. FRC 90. Supd Air 91. To Teal Creams/Re eilants 92. Gloves: <br /> 93. [ Fire Watch 94. [� Drip Pans 95. Plastic Sheerin 96. Vac Truck 97. all Protection <br /> 98. Barricade 99, [� Fire Blanket 100.E] U wind Areas Checked 101. Warning Si <br /> l02. F O Area I03. Li a Lines <br /> 104,A Fire Extiniruisher at Jobsite 105.[ Sampling Prohibited <br /> 106.❑ Seal Manholes,Sewers,and Catch Basins ,107.0 Communication Method 1.108. Welding Shields <br /> 109.Q Continuous Monitoring 1110. Wet Down Area 111. Ladder Tie Off <br /> 112. !�jg Lines 113.Q Active Site Hazard Communication <br /> 114.❑Fence Off Area 115.❑ Other: <br /> i�!REfl[.t REI?PRGC <br /> ❑Drilling ❑Mh Dom ©Traffic Control ❑LOITOIBhnding ❑Hoist/Lifting ❑Journey Hazard Assessment <br /> `t. ..- � "� :; in -� <br /> C]Has Work / []Ground Disturbance ! ❑Confined Torkin ron;Hei hts None y <br /> Contradof.sl/EmWyee(S}.St0l tum,Ihave reviewcdand uadctstandlilCWIId10a <br /> din permit,aW Its avaciww ts. I will¢port baratdcas annditrcaa m acts identified on <br /> job site to my mVavimx and ror 8P mptraentadve so&y can be omeekd as exam y. -..-..... <br /> 5. 6. 7. 8. <br /> 9. 10, It. 12. <br /> Onsite Project Manage6 Date: 1 { Location of Site Work: %, <br /> Site Dated e Issu :r•/ m/ Date/Time Expires:{ i 7 tn/ <br /> Xls HASP onsite? s ERP onsi ?iis ISA onsite? <br /> Authorization Sign ure: <br /> E <br /> Ra•4"000,Dale:07MM <br />