6601084_QMC_Ground Disturbance Permit

EXCAVATION/GROUND DISTURBANCE PERMIT
Trenching and Excavation Procedure HSEOP-05-01

This permit must be completed by a Competent Person before the start of any ground disturbance, trenching, or excavating.
Project Name and Number:*
Company:*
Contractor Drawing Reference Page #(s): (if applicable)
Work Area:*
Location of Excavation:*
Reason for Excavation:*
Start Date:*

YearMonthDay
Date
Permit Expiration Date:*

YearMonthDay
Date
Name of Competent Person Responsible for Excavation:*
Competent Person Phone Number:*
WaterSewerGasPowerFire LinesProcess LinesOther
Utility Comments: (optional)
% O2Explosion TestingGas/Fume TestingStandby PersonHand Excavate at Utility CrossingGrounding of toolsBarricadesSpecial ClothingOther
Special Precautions/Requirements Comments: (optional)
COMPETENT PERSON CHECKLIST
Stable RockType AType BType C
YESN/A
YESNON/A
YESN/A
YESN/A
YESN/A
Are any other obstructions or hazards present? If so, describe them below: (optional)
YESNON/A
YESNON/A
YESN/A
StairwaysLaddersRamps
Note: Sloping/benching for excavations deeper than 20 feet need to be designed by an engineer.
Slope of excavation will be:*
Depth of Excavation:*
Width of Excavation:*
Length of Excavation:*
Any Additional Comments on Excavation: (optional)
Date:*

YearMonthDay
Date
Competent Person Name:*
Competent Person Signature:*

Clear
Superintendent Name:*
Superintendent Signature:*

Clear
Client Representative Name: (if in an operating facility, optional)
Client Representative Signature: (optional)

Clear
NPCL HSE Representative Name:*
NPCL HSE Representative (obtain this signature last)*

Clear
Should be Empty:

EXCAVATION/GROUND DISTURBANCE PERMIT

COMPETENT PERSON CHECKLIST

Note: Sloping/benching for excavations deeper than 20 feet need to be designed by an engineer.