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BASIN Job Project Name: <br /> Job Number: <br /> I V Job <br /> Address: <br /> Job Phone: Job Fax: <br /> SAFETY PLAN CHECKLIST <br /> The below is a typical Safety Plan Checklist to assist in identifying and developing a project —specific safety plan.This <br /> checklist is to be submitted to the Tidal Basin Project Manager/Safety Department before beginning work. <br /> Date: <br /> iSubcontractor: <br /> Specific Project/Task: <br /> 1 Potential Work/Site <br /> Hazards Identified: <br /> ❑Chemical Hazards ❑Fire Hazards ❑Confined Space(s) El Fall Hazards ❑Electrical Hazards <br /> El Silica Hazard ❑Machine Guarding ❑Welding/Cutting El Scaffolding ❑Floor/Wall Openings <br /> ❑Traffic Control ❑Leading Edge Work ❑Asbestos Hazard ❑Heavy Equipment ❑Material Handling <br /> ❑Roofing Hazards ❑Lockout/Tag out ❑Demolition ❑Public Protection <br /> 1 PPE Required for Hazards Identified: <br /> ❑Hard Hat ❑Safety Glasses ❑Face Shield ❑Goggles ❑Anchor Devices ❑Dust Mask ❑Boots <br /> ❑Ventilation ❑Respirator ❑Fall Protection ❑Gloves ❑Hearing Protection ❑Other <br /> Other Equipment/Materials/Tools: <br /> ❑Scaffolds ❑Ladders ❑Stairways ❑Hoists ❑First Aid ❑Task Lighting ❑Temp Power ❑Cranes ❑Barricades <br /> Permits/Plans Required to Accomplish Project: <br /> ❑CIPP ❑Pre-Task Planning ❑Open Flame Permit ❑Hot Work Permit(Electrical) ❑Chemical Use Plan <br /> ❑Confined Space ❑Excavation Permit ❑Fall Protection Plan ❑Hot Work(Welding,etc.) ❑Critical Lift Plan(Cranes) <br /> The Competent Person responsible ON SITE for implementation of this plan is listed below. This individual will be available <br /> at all times to monitor work being performed on this project. <br /> 1 Name/Title Phone: Mobile/Office Date <br /> By submitting this document, I affirm that my personnel have received or will receive the required OSHA safety training prior <br /> to performing the work on this project. A detailed site-specific safety plan shall be submitted to Tidal Basin prior to work <br /> beginning on the project. <br /> Deputy Project Manager Phone: Mobile/Office Date <br /> Based on the above Information, the subcontractor may proceed with their work on this project. <br /> COMMENTS: (DEPUTY PROJECT MANAGER) <br /> I <br /> • <br /> COMMENTS: (PROJECT MANAGER): <br /> I <br /> Received By: Tidal Basin Project Manager Date <br /> • <br /> INote: Additional specific safety plans may be required as noted in the contract/scope of services. <br /> • <br /> Rev:05/2018 <br /> 1 <br />