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Disturbance <br /> Subsurface Clearance Location <br /> Location Disturbance Designation: <br /> ERMPermit. ERM Project No.: <br /> SSC Exp.Person: <br /> Contact Person Approval of Ground Disturbance Locations indicate verbal approval by printing"Verbal"in the signature sace <br /> Name Print Company Name Sin Date/Time <br /> Critical Zone Determination and Clearance Depth It is not referred to initiate Ground Disturbance Activities within a Critical Zone <br /> This Location Is: <br /> If the Disturbance Location Inside a Critical Zone. Partner-in-Charge is aware&approved disturbance at this location. Physical <br /> is known or suspected to ® Clearance will proceed to the deeper of: 0.6m/2 feet below the frost line,2.3m/7 feet below ground <br /> fall within a Critical Zone, <br /> then a sketch(see reverse) level,or 20%deeper than the expected invert elevation of the service <br /> or other map must be <br /> used to confirm proximalF] Outside a Critical Zone. <br /> Critical Zones. Physical Clearance will proceed to the deeper of: 0.6m/2 feet below the frost line or 1.2m/4 feet below <br /> ground level. <br /> Ph"sical Clearance Technique at This Location ,; <br /> Cleared using the following technique: <br /> ❑ None. Waived by PIC. (Ensure documentation in the HASP.) <br /> Reason: Date!Time: <br /> Physical,Clearance Executed&Observed B`" <br /> Company Representatives Date/Time Complete Notes <br /> INas'any Subsurface"Strticture dis+"av'ered iari4 ed yr undaRma"`ed durin ,Clearance? <br /> NoDiscussed with PIC(Date/Time): <br /> (Proceed) F Yes If Yes: <br /> Agreed Action: <br /> SSC Process Complete, <br /> Name of SSC Experienced Person Print Name Sin Date/Time <br /> ERM Health&Safety Page 1 of 2 Last Rev: Sept.2009 <br /> English Version <br />