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BLAINE Daily Tailgate Safety Meeting Checklist & <br /> TecriSERwces Hazard Mitigation Form TGSM <br /> Site Address: G 5 R�Nr 14wq�,ru , , A Date,6/17f ZOiy <br /> Check-In with site representative completed? NL Yes ❑NIA <br /> Is fuel delivery scheduled for today? ❑Yes El No ( N/A <br /> Emergency pump cut-off switch located? ❑Yes ®NIA <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? 9 Yes <br /> Site Status confirmed or amended, dated and initiated? 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 m N1A <br /> Traffic Control Plans reviewed for suitability given current road,traffic&weather conditions? ❑Yes NIA <br /> Stop Work Authority reviewed and understood by all work crew members? res <br /> • In the space below, note unaddressed hazards and conditions that might compromise compliance with Approved <br /> Procedures and/or JSNs 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 ashazards 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 inpi M Hazard Control Measure <br /> Site representative briefed on planned work activities and Work Area Plans? ❑Yes NIA <br /> Job Clearance Form completed? ®Yes <br /> Pre-Start Call-in completed and approval to start work received from Project Manager? Q Yes <br /> Printed Name Signature Time z2eo— <br /> C <br /> TGSM v6 <br />