Moss

GROUND PENETRATION CHECK LIST

This Check List should be reviewed prior to penetrating the ground greater than 6 inches anywhere on site. The contractor disturbing soil is required to contact the locater and review as-builts. J.H.A. is encouraged to be submitted prior to commencing all ground-penetrating activities on site. And prior to the start of the work in the field, the supervisor will conduct a Pre-Task meeting with the crew performing the work.

Date:

Job Site

Company requesting excavation / surface penetration:

1. Name of Superintendent / Foreman:

Phone:

Anticipated Dates of Work:

Anticipated Hours of Work:

Remarks / Clarifications (as necessary):

Location of excavation or surface penetration:

(attach plan)

Description of Work:

Means of disturbing soil (check one):

Excavator/Heavy Equip

Backhoe

Pneumatic Driver (fence posts)

Drilling/Auger

Motorized Saw

Hand Removal (Shovel)

Other:

Contractor's Proposed Method of Identifying Known Utilities (Select One)

1. Vacuum Excavating

Yes No

2. Ground Penetrating Radar

Yes No

3. Hand Excavation

Yes No

4. Other, Explain:

5. Were all known utilities identified?

Yes No

If no, which known utilities were not identified and why?

Layout of Proposed or New Work (Select One)

1. Has the Contractor clearly identified the line of the proposed excavation

Yes No

Utility Locate Organizations:

1. Identify organizations that have completed utility locates.

(date/permit)

Approved Private Locator Company Name:

Method of Locating:

Identified Utilities:

Have all known Utilities around the facility been physically located on the ground as applicable? Identify point of origin and point of termination of each line.

a. Power

Yes No NA

b. Control

Yes No NA

c. Grouding

Yes No NA

d. Comm / Data

Yes No NA

e. Water

Yes No NA

f. Sewer

Yes No NA

g. Gas

Yes No NA

h. Other

Yes No NA

Utility Delineation:

Has a ten-foot utility channel “five feeton either side of the known utilities” been marked or delineated with snow fence, orange silt fence or the equivalent where the new work crosses the utility to ensure adequate recognition?

Yes No

As Built Reviewed? (Select One)

Yes No

Date of Drawings/Docs:

Documented Safety Preplanning Meeting:

Yes No

Are any overhead lines in the area?

Yes No

If yes, they MUST be marked at ground level with signage. Have the areas beneath the concrete slabs been X-rayed prior to any saw cutting or removal? (Select One) Yes No

Yes No

Competent Equip Operator. (Print):

Foreman (Print):

Spotter Required? (Select One):

Yes No

Are there existing utilities in the area described in this request?

Yes No

IF YES, the areas to be excavated are clearly marked-out and utilities within or near the proposed excavation will be “pot-holed" every 15 feet at a minimum using a vacuum process and protected through backfill operations. If multiple known existing utilities are within or near the proposed excavation, increased potholing will be required as determined on the JHA. Unknown existing utilities may be in the area of the work and excavation shall be done with due diligence, strict adherence to the Job Hazard Analysis (JHA), and awareness to prevent damage to unknown utilities.

Subcontractor Superintendent/Foreman:

Clear Signature

MOSS Superintendent:

Clear Signature

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GROUND PENETRATION CHECK LIST

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