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BLAINE Daily Tailgate Safety Meeting Checklist & TG*M <br /> TECHSERVICLs Hazard Mitigation Form f�YY11 <br /> Site Address: � n Date: <br /> s6 11012°l3 <br /> Check-In with site representative completed? ❑Yes ( N/A <br /> Is fuel delivery scheduled for today? ❑Yes LINO ®N/A <br /> Emergency pump cut-off switch located? ❑Yes ( N/A <br /> First aid kit located and confirmed ready-to-use? Yes <br /> Fire extinguisher located and confirmed ready-to-use? Yes <br /> Eye wash located and confirmed ready-to-use? Yes <br /> Emergency Services information located&reviewed? Yes <br /> Hospital map&route located and reviewed? Yes <br /> HASP Special Hazard Notice section reviewed? Yes <br /> Site Status confirmed or amended,dated and initialed? ®Yes <br /> Emergency Response procedures reviewed with all work crew members? Yes <br /> Compliance Roster signed by all work crew members? Yes <br /> Site walk has been performed to locate wells and identify additional hazards? Yes <br /> Job Safety Analysis(JSA)for each task located & reviewed by all work crew members? Yes <br /> Work Area Plans reviewed for suitability and effectiveness given current site conditions? ❑Yes NIA <br /> Traffic Control Plans reviewed for suitability given current road, traffic&weather conditions? ❑Yes RN/A_ <br /> Stop Work Authority reviewed and understood by all work crew members? N Yes <br /> • In the space below,note unaddressed hazards and conditions that might compromise compliance with Approved <br /> Procedures and/or JSA's or impede the safe and proper execution of the Work Plan,Work Area Plan(s)and/or Traffic <br /> Control Plan(s). <br /> • Report unaddressed hazards and adverse conditions to the Project Manager during Pre-Start Call-in and as hazards are <br /> identified or conditions change throughout the workday. <br /> • DO NOT COMMENCE OR RESTART WORK until PM has been notified and mitigation measures approved. <br /> Time Hazard or Adverse Condition Initials PM Hazard Control Measure <br /> Site representative briefed on planned work activities and Work Area Plans? ❑Yes N-N/A <br /> Job Clearance Form completed? iaYes <br /> Pre-Start Call-In completed and approval to start work received from Project Manager? Ryes <br /> Printed Name Signature Time /5 2,5' <br /> TGSM v6 <br />