EXCAVATION PERMIT

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					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 Surveying is 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                                   Frank Robinson             269-833-5754
                  Fire Protection Systems                            Mike Elkins                269-833-5272
                                                                           Paul Groniger        269-833-7905         Bruce Howard        269-833-6139
                  Manager/TL Reviewed & Endorsed Excavation                Vincent Massa        269-833-1168         Kathy Young         269-833-9347
                  Approach                                                 Tom Fletcher         269-833-0882
                                                                           John Simmonds        269-833-6784
               (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/discussed with 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:                                                                     III. Excavation Method (continued)
  Company Name in charge of excavation:                                                        Requirements (each required in all cases)
  † “Qualified Person” (QP) in charge of excavation, Name:                                            Hand Dig – required within 2ft of identified utility or suspected
  † MIOSHA defines a “Qualified person” means one who, by possession of a                             area
  recognized degree, certificate or professional standing, or who by extensive                        Probe – probe depth must exceed soil layer to be removed
  knowledge, training, and experience, has successfully demonstrated his ability to                   and align with industry practices
  solve or resolve problems relating to the subject matter, the work or the project                   Structure Adjacency – Required to hand dig within 20ft of
  † - “ Prime Supplier Safety Rep.                                                                    adjacent building, tank, or structure unless an approved
  Name:                  Contact Number:                                                              alternate method is in place & supervised by Pfizer Safety,
                                                                                                      CM or CAS.
  II. Review the following, for consideration of required actions:                             Yes N/A
  Check required boxes:                                                                                     Mechanical Equipment (Backhoe, bobcat, etc.)
  For changes in vehicular traffic or road closing contact the following:                                   Wet Hydro Excavation to Expose Utilities (Pot holing)*
                              Fire Station 833-2155                                                         Auger (posts)
                              Transportation 833-3767                                                * No dry vacuum allowed due to static electricity
                              Security 833-3636
                              Pfizer CM 833-0882 (Site Construction Notice)                    IV. Shoring, Shielding or Sheeting:
  Complete                                                                                     Protection system methods to protect workers from cave-in, material that
           All equipment, including personal protective equipment, shoring material,           may fall, roll from excavation face or in excavation, & adjacent structure
           signs, barricades and machinery have been reviewed and obtained.                    collapse.
           Equipment and personnel at minimum of 10' or greater away from                      Check required boxes: (those that apply)
           electrical lines. Overhead electrical systems identified and signage of                Vapor Monitoring – required 4’ or deeper when occupied
           Hazard Shall be posted. (Check Complete If Not Applicable)                             Excavation is less than 4’ deep (shoring not required)
           Other known hazards (i.e. overhead obstructions, footings, concrete                    Angle of Repose/Sloping (soil type selection in Section 3)
           encasements, roadways and sidewalks)                                                   Trench Box
                                                                                                  Engineered Shoring System
 III. Soil Type and Method: Check Type – MIOSHA Types Identified below:                           Field Designed Shoring System by Professional Engineer
          (a) “Fill” - a manmade soil condition that may be constructed of any                    Excavations 20’ or deeper deigned by a State/County registered
 type of soil or combination thereof. (1:1 Angle of repose)                                       Professional Engineer PE.
          (b) “Granular soil” – a course grained soil that does not possess cohesion                 - Sloping or benching for excavations greater than twenty (20') feet
 but derives its strength from internal friction. (1-1/2:1 Angle of repose)                            deep shall be designed by a State/County registered Professional
          (c) “Organic soil” - a soil that contains significant amounts of peat, muck                  Engineer.
 or marl. (2:1 Angle of repose)                                                                Supporting Documentation Obtained?                  Yes




           Version 8 – August 1, 2011
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.
         o 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
          o Ladder: with ladder extended 3’ above top of excavation
          o 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

                                                                                                  Trade Type,
                                                                      Print Name                                      Competent
      Additional Suppliers Working in Excavation                                                      i.e.
                                                                   Competent Person &                               Person Sign for                  Date
                   (Supplier Name)                                                                 Electrical,
                                                                     Phone Number                                      Approval
                                                                                                  Piping, Etc
 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




        Version 8 – August 1, 2011
                                           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:                  Print Name:               Print Name:               Print Name:                Print Name:



Initial:                     Initial:                  Initial:                  Initial:                   Initial:


DATE:                        DATE:                     DATE:                     DATE:                      DATE:
Print Name:                  Print Name:               Print Name:               Print Name:                Print Name:



Initial:                     Initial:                  Initial:                  Initial:                   Initial:

DATE:                        DATE:                     DATE:                     DATE:                      DATE:
Print Name:                  Print Name:               Print Name:               Print Name:                Print Name:



Initial:                     Initial:                  Initial:                  Initial:                   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.
                                 o Retest is required if Excavation is left unattended
                            Presence of Toxic Fumes - If “Yes”, STOP ALL work and notify
                                 o Environmental @ 833-6152.
                                 o Notify your Pfizer contact and the KCA Safety Rep.

                           The O2 and 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                    BUMP TEST                 BUMP TEST                 BUMP TEST                  BUMP TEST
      RESULTS                      RESULTS                   RESULTS                   RESULTS                    RESULTS
O2 :                         O2 :                      O2 :                      O2 :                       O2 :
LEL:                         LEL:                      LEL:                      LEL:                       LEL:
     SITE TEST                    SITE TEST                 SITE TEST                 SITE TEST                  SITE TEST
      RESULTS                      RESULTS                   RESULTS                   RESULTS                    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             UNIT # / COMPANY          UNIT # / COMPANY          UNIT # / COMPANY           UNIT # / COMPANY
NAME:                        NAME:                     NAME:                     NAME:                      NAME:



CP:                          CP:                       CP:                       CP:                        CP:

DATE:                        DATE:                     DATE:                     DATE:                      DATE:
     BUMP TEST                    BUMP TEST                 BUMP TEST                 BUMP TEST                  BUMP TEST
      RESULTS                      RESULTS                   RESULTS                   RESULTS                    RESULTS
O2 :                         O2 :                      O2 :                      O2 :                       O2 :
LEL:                         LEL:                      LEL:                      LEL:                       LEL:
     SITE TEST                    SITE TEST                 SITE TEST                 SITE TEST                  SITE TEST
      RESULTS                      RESULTS                   RESULTS                   RESULTS                    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             UNIT # / COMPANY          UNIT # / COMPANY          UNIT # / COMPANY           UNIT # / COMPANY
NAME:                        NAME:                     NAME:                     NAME:                      NAME:




Version 8 – August 1, 2011

				
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