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N%.W1 Attachment C—Site Safety & Health Plan Safety Plan Implementation Checklist Project Name Project Location{city and state) Date Name of Site Safety Officer Weather Conditions Project Number BC Staff Present Name Office Indicate the status of each of the following. 1. Is a copy of the Site Safety and Health Plan(SSHP)on site? ❑ YES ❑ NO ❑ N/A 2. Is the personal protective equipment required by the SSHP available and being ❑ YES ❑ NO ❑ N/A used correctly? 3. Have the work zones been delineated? ❑ YES ❑ NO ❑ N/A 4. Has a decontamination station been set up as required by the SSHP? ❑ YES ❑ NO ❑ N/A 5. Are the decontamination procedures being followed? ❑ YES ❑ NO ❑ N/A 6. Is access to the exclusion zone being controlled? ❑ YES ❑ NO ❑ N/A 7. Has the site activities briefing and tailgate safety meeting been provided? ❑ YES ❑ NO ❑ N/A 8. is the list of emergency telephone numbers posted at the support zone? ❑ YES ❑ NO ❑ N/A 9. Are directions to nearest emergency medical assistance posted at the support zone? ❑ YES ❑ NO ❑ N/A 10. Is emergency equipment available and functional,as required by the SSHP? ❑ YES ❑ NO ❑ N/A 11. Has the nearest toilet facility been identified or a portable facility been set up? ❑ YES ❑ NO ❑ N/A 12. Has an adequate supply of drinking water been provided? ❑ YES ❑ NO ❑ N/A 13. Has water for decontamination been provided? ❑ YES ❑ NO ❑ N/A 14. Have the instruments for environmental and exposure monitoring been calibrated ❑ YES ❑ NO ❑ N/A and set up as required by the SSHP? 15. Are the instruments being used properly and periodically checked during the ❑ YES ❑ NO ❑ N/A shift for battery charge status? 16. Have trenches and excavations been clearly marked? ❑ YES ❑ NO ❑ N/A 17. Have trenches and excavations been shored or sloped as required by soil ❑ YES ❑ NO ❑ N/A type and work activities? 18. Are dust suppression measures being used? ❑ YES ❑ NO ❑ N/A 19. Is food and tobacco consumption being restricted to the support zone? ❑ YES ❑ NO ❑ N/A 20. Has a confined space been identified as part of this project? ❑ YES ❑ NO ❑ N/A 21. Are the confined space entry procedures being correctly implemented? ❑ YES ❑ NO ❑ N/A 22. Has the work/rest cycle for the shift been established? ❑ YES ❑ NO ❑ N/A TIME ON (minutes): TIME OFF (minutes): 23. Has a shaded rest area been set up in the support zone? ❑ YES ❑ NO ❑ N/A BROWN and CALOWELI Place completed farm in project file. Hs'1ahm REV.IMI