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Chevron EMC Retail & Terminal Business Unit BOREHOLE CLEARANCE REVIEW (Specific for service station assessments) • Chevron Site# Protect# 774f{ fY27d-, - BorehoIe#s Reviewed i✓ Date Z/o Ap, Clearance Inspected by l ft � Reviewed by Yes No (Contractor/Consultant Rep)� (Contractor/Consultant PM Initial) ❑ l Is a scaled site plan showing the proposed borehole locations attached to this form? ❑ 2 Are all of the proposed borehole locations at Ieast 5 feet from any subsurface utilities(including product lines)shown on Chevron's building plans? ❑ 3 Are all of the proposed borehole locations at least 7 feet from the pad surrounding the underground storage tanks(USTs)shown on Chevron's building plans? ❑ 4 Are all of the proposed borehole locations at least 5 feet from any subsurface utilities shown on public right-of-way street iw6ovement plans? PM to check here El if applicable to this,lob ❑ 5 Does the station manager have any knowledge of any subsurface utilities within 5 feet of the proposed borehole locations? (Review locations with the station manager) ❑ 6 Are all of the proposed bo hole locations at least 5 feet from any subsurface utilities identified during a geophysical surve ? PM to check here 12rif applicable to this fob L ❑ 7 Have all underground service alert providers notified by USA marked out their facilities in the vicinity of the borehole locations or otherwise notified EMC'S Contractor/Consultant that they do not have any facilities near the proposed borehole locations? • ❑ 8 Do any of the proposed borehole locations lie on a line connecting two similar looking manhole covers? ❑ 9 Do any of the proposed borehole locations lie on a line perpendicular to the street from the water,gas, and electrical meter? ❑ 15�r 10 Has the pavement in the vicinity of any of the proposed borehole locations subsided or does it give the appearance it may be covering a former trench? ❑ I 1 Do any of the proposed borehole locations lie beneath overhead utility Imes or canopies that may interfere with the drilling rig? i ❑ 12 Have all appropriate permits been obtained? ❑ ❑ 13 Have you carefully cleared the hole(using an air knife,hand auger,or other mechanical methods)to a minimum depth of 8 feet below grad before using the drill rig? ❑ ❑ 14 Is the diameter of the hand cleared hole greater than the outer diameter of the drilling tools you will be using(at least 120%the drilling tool diameter)? ❑ ❑ 15 ,.Does the soil you encountered in the cleared hole consist of clean gravel,Glean sand,aggregate base :;-, 5#r .r; (gravelly sand with---10%fines),or non-native looking material? Questions I through I2 must be answered prior to mobilizing a drilling rig to the site Questions 13 through 15 should be answered prior to drilling by the field staff DO NOT DRILL,if you answered NO to questions 1,2,3,4,6,7, 12, 13 or 14 or answered YES to questions 5, 8, 9, 10, 11 or 15 Contact the EMC Contractor/Consultant project manager for instructions prior to drilling and describe the conflict on the back of this form ,Reference—AntiEntroptcs,Inc in coordination with Isltional Drilling Association,Environmental Remediation Drilling Safety Guideline,Revision 0,2005 Drdimg safety_ChecklistRev F Rev 08/26/05