EXCAVATION PERMIT

This permit is required for any excavation, digging, soil removal, or ground disturbance on Pfizer property.Complete all sections.

In case of quick response (broken utility line continuing to leak, creating an increasingly dangerous situation), contact Safety as defined in Section 2,execute the intent of the permit and resolve the situation in safest possible manner.With site utility drawing in-hand and a 100% hand dig excavation, Sections 3 and 4 are not needed.

1. Project Information
Project Name: / Pfizer Contact: Construction Manager (CM), Const. Admin. Specialist(CAS) / Start Date:
Estimated Completion Date:
2. Job Description and Location (Be Specific)
Identify Site: Portage Downtown Richland B212 B248
Contact Safety: Anita Pelak 269-217-0454 Joe Urnowey 269-720-9666 Pat Brown 269-207-4073 Jack Routley 269-217-9865
3. Pre-Excavation: Identifying Underground Hazards!– Initiate 2-3 weeks before excavation.
Mandatory:Contacting the following departments is mandatory; they will assist in identifying underground systems located of your planned dig area.
If any of the departments have concerns with this excavation area, Underground Surveyingis required!
Complete / Area / Contact Name / Phone / Comments
Soil Management / Bill Hunsberger / 269-833-6152
Communications, phone, fiber optic’s etc. / Pat Vanderbush / 269-833-0236
Electrical Systems / Jim Taylor / 269-833-9670
Water Department / Garry Henson / 269-833-4948
Fire Protection Systems / Mike Elkins / 269-833-5272
Manager/TL Reviewed Endorsed Excavation Approach / Dan Roth
Vincent Massa
John Abee
John Simmonds / 269-833-8051
269-833-1168
269-833-7077
269-833-6784 / Bruce Howard
Kathy Young
Tom Fletcher / 269-833-6139
269-833-9347
269-833-0882
(IF Applicable) Trestles and Utilities Systems / Andrew Redlon / 269-833-1633
(IF Applicable) Miss Dig: right of way or easement / Miss Dig / 800-482-7171
4. Underground Utility Location
Complete / Task
Construction Manager provided site drawing with excavation zone identified.
Pre-surveying meeting occurred with Surveyor, SME’s, CM, & Excavation Firm (Operator attendance preferred)
CM escorted utility surveyor and maintained accuracy and potential problematic areas on sketch & provided/discussedwith excavation firm.
Post survey meeting occurred with Surveyor, SME’s, CM, & Excavation Operator on morning of commencement.
Ground Penetrating Radar (GPR) Conducted (recommend <2 weeks prior)
Radio Frequency Testing Conducted (recommend <2 weeks prior)
All utilities marked per APW uniform color codes.
Surveyor Technician
Print Name: / Firm Name:
Signature: / Date:
5. Excavation Requirements
I. Required Information:
Company Name in charge of excavation:
† “Qualified Person” (QP) in charge of excavation, Name:
† MIOSHA defines a “Qualified person” means one who, by possession of a recognized degree, certificate or professional standing, or who by extensive knowledge, training, and experience, has successfully demonstrated his ability to solve or resolve problems relating to the subject matter, the work or the project
† - “ Prime Supplier Safety Rep.
Name: Contact Number:
II. Review the following, for consideration ofrequired actions:
Check required boxes:
Forchanges in vehicular traffic or road closing contact the following:
Fire Station 833-2155
Transportation 833-3767
Security 833-3636
Pfizer CM 833-0882 (Site Construction Notice)
Complete
All equipment, including personal protective equipment, shoring material,signs, barricades and machinery have been reviewed and obtained.
Equipment and personnel at minimum of 10' or greater away from electrical lines. Overhead electrical systems identified and signage of Hazard Shall be posted. (Check Complete If Not Applicable)
Other known hazards (i.e. overhead obstructions, footings, concrete encasements, roadways and sidewalks)
III. Soil Type and Method: Check Type – MIOSHA Types Identified below:
(a) “Fill” - a manmade soil condition that may be constructed of any
type of soil or combination thereof. (1:1 Angle of repose)
(b) “Granular soil” – a course grained soil that does not possess cohesion but derives its strength from internal friction. (1-1/2:1 Angle of repose)
(c) “Organic soil” - a soil that contains significant amounts of peat, muck or marl. (2:1 Angle of repose) / III. Excavation Method (continued)
Requirements (each required in all cases)
Hand Dig – required within 2ft of identified utility or suspected
area
Probe– probedepth must exceed soil layer to be removed
and align with industry practices
Structure Adjacency – Required to hand dig within 20ft of
adjacent building, tank, or structure unless an approved
alternate method is in place & supervised by Pfizer Safety,
CM or CAS.
Yes N/A
Mechanical Equipment (Backhoe, bobcat, etc.)
Wet Hydro Excavation to Expose Utilities (Pot holing)*
Auger (posts)
* No dry vacuum allowed due to static electricity
IV. Shoring, Shielding or Sheeting:
Protection system methods to protect workers from cave-in, material that may fall, roll from excavation face or in excavation, adjacent structure collapse.
Check required boxes:(those that apply)
Vapor Monitoring – required 4’ or deeper when occupied
Excavation is less than 4’ deep (shoring not required)
Angle of Repose/Sloping (soil type selection in Section 3)
TrenchBox
Engineered Shoring System
Field Designed Shoring System by Professional Engineer
Excavations 20’ or deeper deigned by a State/County registered
Professional EngineerPE.
- Sloping or benching for excavations greater than twenty (20') feet deep shall be designed by a State/County registered Professional Engineer.
Supporting Documentation Obtained? Yes
Continued from Section 5
V. Protection from hazards associated with excavations: Check after reviewing:
Water Accumulation:
  • Employees shall not work in excavations in which there is accumulated water, or in excavations, in which water is accumulating, unless adequate precautions have been taken to protect employees against the hazard(s) posed by water accumulation.
  • If water is controlled or prevented from accumulating by use of water removal equipment, the equipment & operations shall be monitored by a “Qualified Person” to ensure proper operation.
General Safety Precautions:
  • Hard Hat, Safety Glasses w/side shields, Safety toed work boots and Gloves required.
  • If marking are lost or disturbed, replace markings before continuing with excavation.
  • For extensive delays in excavation, a new Permit and survey is required.
Guarding, Barricade, Signs
  • Protection shall be provided by placing and keeping such material or equipment at least 2' from edge of excavation.
  • Hard barricade or snow fence required. (No Barrier Tape)
  • Display contact information at excavation( ie, Pfizer contact, Qualified person, Supplier Safety Rep. and Pfizer Safety Rep.)
Egress within Trench or Excavation > 4’ deep
  • No more than 25’ of lateral travel is required for workers to Egress
  • Ladder:with ladder extended 3’ above top of excavation
  • Ramp:
  • An earth ramp may be used in place of a ladder if the following requirements are met:
(a) The ramp material shall be stable.
(b) The sides of the excavation above the ramp shall be maintained to the angle of repose or sheeted or shored along means of egress.
(c) The degree of angle of the ramp shall not be more than 45 degrees.
(d) Vertical height between the floor of the trench and the toe of the ramp shall not exceed 30 inches.
Backfill Requirements
  • All earth removed from the excavation must remain on-site and reused for backfill.
  • Warning Tape must be used 1ft above all new utilities and any exposed existing utilities.
  • Utility trace wire installed on all new utilities.
  • As-built drawings must be confirmed before covering warning tape.
  • Confirm no dead end branches and all capped lines are demolished at the main.

6. Approval:
Excavation Requirements Review:
  • >20 Feet in Depth needs to have an approval stamp from a qualified civil engineer.
  • Excavation permits are required to be “Kept” at job sites and available for review during work.
  • Soils will be kept 2’ away from excavation edge!

Approvers / Print Name / Sign for Approval / Date
Qualified Person †
(Responsible for day to day Inspection and conditions of excavation.)
Pfizer Rep./Requestor (CAS/CM)
Pfizer Safety Representative
Contracted Supplier Working in Excavation
All suppliers working in this excavation have read and agreed to the conditions set by the “Permit Requirements”. In addition, responsible person confirms that all entering workers have received excavation training from their company.
†Competent Person:
Means one who is capable of identifying existing and predictable hazards in the surroundings or working conditions which are unsanitary, hazardous, or dangerous to employees, and who has the authorization to take prompt corrective measures to eliminate them
Additional Suppliers Working in Excavation
(Supplier Name) / Print Name
Competent Person &
Phone Number / Trade Type, i.e. Electrical, Piping, Etc / Competent Person Sign for Approval / Date
Supplier Name working in excavation
Supplier Name working in excavation
Supplier Name working in excavation
Supplier Name working in excavation
7. Permit Completion:
Construction Manager / Print Name / Sign / Date
Construction Manager
Excavation is backfilled and job is complete. CM to retain with project file.
r

Daily Inspection Log by Qualified Person

MIOSH PART 9 - R 408.40932 Excavation;

5.An ongoing inspection of an excavation or trench shall be made by a qualified person. After every rainstorm or other hazard-producing occurrence, an inspection shall be made by a qualified employee for evidence of possible slides or cave-ins. Where these conditions are found, all work shall cease until additional precautions, such as additional shoring or reducing the slope, have been accomplished.

Date and sign for day of inspection by the Qualified Person prior to any entry into excavation

DATE: / DATE: / DATE: / DATE: / DATE:
Print Name:
Initial: / Print Name:
Initial: / Print Name:
Initial: / Print Name:
Initial: / Print Name:
Initial:
DATE: / DATE: / DATE: / DATE: / DATE:
Print Name:
Initial: / Print Name:
Initial: / Print Name:
Initial: / Print Name:
Initial: / Print Name:
Initial:
DATE: / DATE: / DATE: / DATE: / DATE:
Print Name:
Initial: / Print Name:
Initial: / Print Name:
Initial: / Print Name:
Initial: / Print Name:
Initial:

Atmospheric Monitoring Entry Log Sheet

Atmospheric Test Requirements:

  • Atmospheric Testing is required with excavations ≥ 4'. Test top and bottom of the excavation
  • Must be conducted no earlier than 1 hour to entering the excavation site.
  • Retest is required if Excavation is left unattended
  • Presence of Toxic Fumes - If “Yes”, STOPALL work and notify
  • Environmental @ 833-6152.
  • Notify your Pfizer contact and the KCA Safety Rep.

The O2and LEL BUMP Test percentages MUST be in the following ranges:

O2: 18.5% - 19.2% LEL: 27% - 33%

CP: / CP: / CP: / CP: / CP:
DATE: / DATE: / DATE: / DATE: / DATE:
BUMP TEST RESULTS / BUMP TEST RESULTS / BUMP TEST RESULTS / BUMP TEST RESULTS / BUMP TEST RESULTS
O2 : / O2 : / O2 : / O2 : / O2 :
LEL: / LEL: / LEL: / LEL: / LEL:
SITE TEST RESULTS / SITE TEST RESULTS / SITE TEST RESULTS / SITE TEST RESULTS / SITE TEST RESULTS
O2 : / O2 : / O2 : / O2 : / O2 :
LEL: / LEL: / LEL: / LEL: / LEL:
METER ID: / METER ID: / METER ID: / METER ID: / METER ID:
INITIALS: / INITIALS: / INITIALS: / INITIALS: / INITIALS:
UNIT # / COMPANY NAME: / UNIT # / COMPANY NAME: / UNIT # / COMPANY NAME: / UNIT # / COMPANY NAME: / UNIT # / COMPANY NAME:
CP: / CP: / CP: / CP: / CP:
DATE: / DATE: / DATE: / DATE: / DATE:
BUMP TEST RESULTS / BUMP TEST RESULTS / BUMP TEST RESULTS / BUMP TEST RESULTS / BUMP TEST RESULTS
O2 : / O2 : / O2 : / O2 : / O2 :
LEL: / LEL: / LEL: / LEL: / LEL:
SITE TEST RESULTS / SITE TEST RESULTS / SITE TEST RESULTS / SITE TEST RESULTS / SITE TEST RESULTS
O2 : / O2 : / O2 : / O2 : / O2 :
LEL: / LEL: / LEL: / LEL: / LEL:
METER ID: / METER ID: / METER ID: / METER ID: / METER ID:
INITIALS: / INITIALS: / INITIALS: / INITIALS: / INITIALS:
UNIT # / COMPANY NAME: / UNIT # / COMPANY NAME: / UNIT # / COMPANY NAME: / UNIT # / COMPANY NAME: / UNIT # / COMPANY NAME:

Version 8 – August 1, 2011