EXCAVATION/GROUND DISTURBANCE PERMIT
Trenching and Excavation Procedure HSEOP-05-01
Project Name
*
Work Performed By
*
Drawing (if applicable)
Location of Excavation
*
Reason for Excavation
*
Start Date
*
/
Month
/
Day
Year
Date
End Date
*
/
Month
/
Day
Year
Date
Person Responsible for Excavation:
*
Phone #:
*
Format: (000) 000-0000.
Utilities Present in Excavation Area (check off all applicable utilities)
*
Water
Sewer
Gas
Power
Fire Lines
Process Lines
Other
Special Precautions/Requirements (check those that apply)
% Oxygen
Explosion testing
Gas/Fume testing
Standby Person
Hand excavate at utility crossing
Grounding of tools
Barricades
Special clothing
Other
Comments
COMPETENT PERSON CHECKLIST
Select soil classification
*
Stable Rock
Type A
Type B
Type C
Have all procedural requirements been met and documented?
*
Yes
No
N/A
Is the excavation close to utilities, buildings, footings, pilings, source of vibration?
*
Yes
No
N/A
Have utilities, etc., been located?
*
Yes
No
N/A
Has a check for the previous excavations in the area been made?
*
Yes
No
N/A
Have adequate supplies of equipment, PPE, shoring material, signs, barricades, machinery, etc. been assured and checked?
*
Yes
No
N/A
Other obstructions/hazards:
Comments
Size of Excavation:
Depth(ft)
*
Width(ft)
*
Length(ft)
*
Do vehicular and machinery operation patterns need to be changed?
*
Yes
No
N/A
Will water removal operations/equipment be needed?
*
Yes
No
N/A
Have trench boxes or trench shields been checked?
*
Yes
No
N/A
Entrance/exit means (maximum travel distance to exit 25 ft.)
*
Stairway
Ladders
Ramps
Note: Sloping/bening for excavations deeper than 20 feet must be designed by a PE
Date
*
/
Month
/
Day
Year
Date
Excavation Competent Person
*
First Name
Last Name
Competent Person Signature
*
HSE Representative
Submit
Should be Empty: