**LBNL Construction Safety Check List**

**[Safety Check List MUST be posted at the job-site.]{.underline}**

Sub-Contractor shall take all reasonable precautions in the performance
of the work under this purchase order to protect safety and health of
employees and members of the public and shall comply with all applicable
environmental, safety, and health regulations and requirements
(including reporting requirements of the University and DOE). In the
event Sub-Contractor fails to comply with these regulations or
requirements, the University may issue an order stopping all or any part
of the work; thereafter, a start order for resumption of work may be
issued at the discretion of the University. Sub-Contractor shall make no
claim for extension of time or for compensation or damages by reason of
or in connection with such work stoppage.

Sub-Contractor shall fill out the attached safety checklist and submit
to Lawrence Berkeley National Laboratory (LBNL) Construction Safety
Engineer for approval prior to start of construction. This checklist
consists of Environmental Protection and Health and Safety items that
are most required of subcontractors and their lower-level subcontractors
when performing work at LBNL. These items and all other requirements in
the contractual documents will be enforced.

To expedite approval, provide additional information where required on
the checklist; Approval will not be complete without the additional
information required.

  ----------------- ----- -- ---- -------- ------ ---------- -------- ------ -- ---------------
  DATE:                                                                         

  Sub-Contractors                                                               
  Company Name:                                                                 

  Project Title:                                                                

  Sub-Contractors                                                               
  Superintendent:                                                               

  Phone No.:                                      Fax No.:                      

  Building                                        Purchase                      
  Location:                                       Order No.:                    

  Detailed                                                                      
  Description of                                                                
  Work:                                                                         

                                                                                

                                                                                

                                                                                

                                                                                

                                                                                

                                                                                

  LBNL Requester:                                            Phone:             

  LBNL Buyer:                                                Phone:             
  ----------------- ----- -- ---- -------- ------ ---------- -------- ------ -- ---------------

**Safety Policy**

**General**

Lawrence Berkeley National Laboratory (LBNL) is committed to providing
and maintaining the safest possible work conditions for all workers by
promoting the integration of safety management into all construction
processes.

Project managers, construction managers, superintendents, assistant/area
superintendents, safety representatives, and foremen are responsible for
implementing and maintaining an effective safety program. It is the
responsibility of these individuals to ensure workers under their
supervision maintain safe work areas and perform their tasks in a safe
manner. It is also the responsibility of each worker to follow every
precaution and LBNL safety rule and policy to protect themselves and
their fellow workers.

LBNL will monitor safety programs and performance to ensure compliance
with LBNL requirements. When performing work at LBNL, each employer:

-   Is responsible for the safety of their employees and/or visitors as
    required by the rules and regulations of this chapter; 10 CFR 851
    "Worker Safety & Health Program"; the California Code of
    Regulations, Title 8, Construction Safety Orders; 29 CFR 1926 Safety
    Standards for the Construction Industry; and all other local, state,
    and federally recognized current standards and codes.

-   Is required to understand and follow the contents of PUB 3000, LBNL
    Health and Safety Plan.

-   Is responsible for training and educating their employees, and/or
    visitors, as to the contents of this chapter and requirements for
    conduct of work under the LBNL Integrated Safety Management (ISM)
    Plan. (Documentation of all training is the responsibility of the
    subcontractor.)

-   Differences of opinion regarding a stop work order between the LBNL
    Project Manager, LBNL Construction Safety Engineer, and others
    involved must be immediately referred to their respective functional
    supervisors for resolution. The recommendations of the LBNL
    Construction Safety Engineer must be followed until a final decision
    is made. Final determination will come from the LBNL Facilities
    Division Director.

This policy applies to all construction activities performed by LBNL
employees; contract employees under the direct technical supervision of
an LBNL employee, referred to as \"contract employees"; and
non-laboratory employees under the supervision of subcontractors,
referred to as \"construction subcontractors.\" Construction activities
may originate from construction subcontracts, service contracts,
purchase orders, and in-house work orders.

**Department of Energy 10 CFR 851, \"Worker Safety & Health Program"**

All work shall comply with the Department of Energy's Worker Safety and
Health Program regulation, 10 CFR 851, which enforces worker safety and
health requirements including but not limited to standards of the
Occupational Safety and Health Administration (OSHA) as incorporated in
the LBNL Worker Safety and Health Program. Violations of safety and
health provisions of 10 CFR 851 may subject to penalties. The employer
shall follow the provisions of its Cal/OSHA mandated Injury and Illness
Prevention Plan (IIPP) and submit it to LBNL when requested. The
employer shall also follow all LBNL safety procedures and policies
communicated in it.

# Mandatory Requirements on All Construction Projects 

**Competent Person**

Provide a written list of those persons onsite who are capable of
identifying existing and predictable hazards in the surrounding or
working conditions which are unsanitary, hazardous, or dangerous to
employees, and who has the authorization to take prompt corrective
measures to eliminate them. The Employer shall ensure that each
competent person listed has been trained in the following areas as
applicable:

Competent
Person:\_\_\_\_\_\_\_\_\_\_\_\_[\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

**Qualified Person**

Provide a written list of those persons onsite who by possession of a
recognized degree, certification, or professional standing, or who by
extensive knowledge, training, and experience, has successfully
demonstrated their ability to solve or resolve problems relating to the
subject matter, the work, or the project. The Employer shall ensure that
each qualified person listed has been trained in the following areas as
applicable: Qualified Person:

Asbestos: Competent Person:

Cranes: Competent Person:

Confined Space: Competent Person:

Demolition: Competent Person:

Electrical: Qualified Person:

Excavations: Competent Person:

Fall Protection: Competent Person:

Ladder: Competent Person:

Scaffold: Competent Person:

Steel Erection: Competent Person:

Underground Construction: Competent Person:

Administrative Poster required on all construction projects:

Federal Employee Rights \_ Equal Employment Opportunity Law\_

Your Rights under Family & Medical Leave Act of 1993

Employee Polygraph Protection Act Your Rights under USERRA

OSHA-Job Safety & Health-It's the Law California Minimum Wage

Discrimination & Harassment in Employment EDD-Employment Development
Department Notice 'A'- Pregnancy Disability Leave Notice 'B'- Family
Care & Medical Leave (CFRA Leave) & Pregnancy Disability Leave EDD
Notice to Employees Pay Day Notice Emergency Postings
(Amublance-Fire-etc.)

Cal/OSHA Safety & Health Protection on the Job Operating Rules for
Industrial Trucks California Prop 65 OSHA Posting for Powder-Actuated
Tools

**Project Specific Construction Safety Checklist**

## Personal Protective Equipment

LBNL Policy Requires Safety Glasses, Hard Hats and Work boots 100% of
the time while working on ALL LBNL construction and Facility maintenance
projects.

+------------------------------------------------------+--------+------+
| Will the work involve hazards that require the use   | YES    | NO   |
| of any of the protective equipment listed below?     |        |      |
+------------------------------------------------------+--------+------+
| Full Face Shields,                                   | YES    | NO   |
+------------------------------------------------------+--------+------+
| Chemical Splash Goggles                              | YES    | NO   |
+------------------------------------------------------+--------+------+
| Welders Hood and Goggles, Leathers Gloves            | YES    | NO   |
+------------------------------------------------------+--------+------+
| Steel Toed Boots,                                    | YES    | NO   |
+------------------------------------------------------+--------+------+
| Ear plugs Or Ear Muffs,                              | YES    | NO   |
+------------------------------------------------------+--------+------+
| Fall Protection**,** is required anytime the worker  | YES    | NO   |
| is above 6 feet.                                     |        |      |
|                                                      | YES    | NO   |
| ***ANSE/ASSE Z359 to be followed. Submit for PPE***: |        |      |
|                                                      | YES    | NO   |
| Fall Protection Plan                                 |        |      |
|                                                      |        |      |
| Training Records                                     |        |      |
+------------------------------------------------------+--------+------+
| Work Gloves, leather, rubber...                      | YES    | NO   |
+------------------------------------------------------+--------+------+
| Electrical PPE,                                      | YES    | NO   |
|                                                      |        |      |
| Head protection (ANSI Z89.1, 1997)                   | YES    | NO   |
|                                                      |        |      |
| Eye & Face (ANSI Z87.1, 1998)                        | YES    | NO   |
|                                                      |        |      |
| Gloves (ASTM D120-02, 2002)                          | YES    | NO   |
|                                                      |        |      |
| Sleeves (ASTM D 1051-02, 2002)                       | YES    | NO   |
|                                                      |        |      |
| Gloves & Sleeves (ASTF 496-02, 2002)                 | YES    | NO   |
|                                                      |        |      |
| Leather (ASTM F 696-02, 2002)                        | YES    | NO   |
|                                                      |        |      |
| Footwear (ASTM F 1117-98, 1998)                      | YES    | NO   |
|                                                      |        |      |
| Visual Inspection (ASTM F 1236-01, 2001)             | YES    | NO   |
|                                                      |        |      |
| Apparel Flame Resistant Clothing (ASTM F 1506-02a,   | YES    | NO   |
| 2002)                                                |        |      |
|                                                      | YES    | NO   |
| Face Protection Products (ASTM F 2178-02, 2002)      |        |      |
|                                                      |        |      |
| Raingear (ASTM F 1891-02a, 2002)                     |        |      |
+------------------------------------------------------+--------+------+
| Respirators,                                         | YES    | NO   |
|                                                      |        |      |
| ***Contractor must submit the following items for    | YES    | NO   |
| Respirator Use :***                                  |        |      |
|                                                      | YES    | NO   |
| Respiratory Protection Plan:                         |        |      |
|                                                      | YES    | NO   |
| Medical Release:                                     |        |      |
|                                                      | YES    | NO   |
| Quantitative Fit Test Records:                       |        |      |
|                                                      | YES    | NO   |
| Qualitative Fit Test Records:                        |        |      |
|                                                      |        |      |
| Training Records:                                    |        |      |
+------------------------------------------------------+--------+------+

##  {#section .unnumbered}

##  {#section-1 .unnumbered}

## Hand and Power Tools

+------------------------------------------------------+--------+------+
| Will the work involve the use of electrically        | YES    | NO   |
| powered tools?                                       |        |      |
+------------------------------------------------------+--------+------+
| Will the work performed on this project involve the  | YES    | NO   |
| use of po**[w]{.underline}**der actuated tools?      |        |      |
|                                                      | YES    | NO   |
| ***Contractor must submit the following items for    |        |      |
| Powder Actuated tools.:***                           |        |      |
|                                                      |        |      |
| Training Records:                                    |        |      |
+------------------------------------------------------+--------+------+

## Ground & Surfaces and Penetration 

  ------------------------------------------------------ -------- -------
  Will the work scope require you to perform             YES      NO
  [any]{.underline} mounting to walls or penetration              
  (including chipping) into the ground, walls floors,             
  sub-floors, and or any excavation, trenching,                   
  including the use of stakes or poles deeper then 1              
  5/8"? If YES, LBNL Dig Permit is required.                      

  ------------------------------------------------------ -------- -------

##  {#section-2 .unnumbered}

## Excavation and Trenching 

+------------------------------------------------------+--------+------+
| Will this work scope involve any excavation below 5  | YES    | NO   |
| feet?                                                |        |      |
+------------------------------------------------------+--------+------+
| Will a Trench box be used?                           | YES    | NO   |
+------------------------------------------------------+--------+------+
| Will Shoring or Shielding be used?                   | YES    | NO   |
+------------------------------------------------------+--------+------+
| Will this work scope involve sewer line repair or    | YES    | NO   |
| replacement?                                         |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Excavation and Trenching***                          |        |      |
|                                                      | YES    | NO   |
| JHA detailing Shoring Plan                           |        |      |
|                                                      | YES    | NO   |
| Training Records                                     |        |      |
|                                                      | YES    | NO   |
| **Atmospheric testing shall apply at 4ft: Where      |        |      |
| oxygen deficiency or hazardous atmosphere exists or  |        |      |
| could reasonably be expected to exist. Such as in    |        |      |
| excavations in areas where hazardous substances      |        |      |
| maybe present ie sewer lines,**                      |        |      |
|                                                      |        |      |
| Excavations 4 feet in depth or greater shall have a  |        |      |
| stairway, ladder, ramp, or other safe means of       |        |      |
| egress within 25 feet                                |        |      |
+------------------------------------------------------+--------+------+

##  {#section-3 .unnumbered}

## Demolition LBNL must complete an Isolation Plan

+------------------------------------------------------+--------+------+
| Have you the Contractor signed off on the Isolation  | YES    | NO   |
| Plan: Electrical, Gas, Water, Steam, or other        |        |      |
| Utilities?                                           |        |      |
+------------------------------------------------------+--------+------+
| Will Flagger be required?                            | YES    | NO   |
+------------------------------------------------------+--------+------+
| Will a traffic safety plan be required?              | YES    | NO   |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Demolition Plan***:                                  |        |      |
|                                                      | YES    | NO   |
| JHA detailing the scope of work                      |        |      |
|                                                      | YES    | NO   |
| Traffic Plan                                         |        |      |
|                                                      |        |      |
| Training Records for Flaggers                        |        |      |
+------------------------------------------------------+--------+------+

##  {#section-4 .unnumbered}

## Traffic Control

+------------------------------------------------------+--------+------+
| Will this work scope require ANY road disruptions?   | YES    | NO   |
+------------------------------------------------------+--------+------+
| Will this work require LBNL Security escort for      | YES    | NO   |
| over-sized loads etc...?                             |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Traffic Control***:                                  |        |      |
|                                                      | YES    | NO   |
| Traffic Plan                                         |        |      |
|                                                      |        |      |
| Training Records for Flaggers                        |        |      |
+------------------------------------------------------+--------+------+

##  Utilities Shut-Off

+------------------------------------------------------+--------+------+
| Will utilities (i.e., electrical, gas, water, steam, | YES    | NO   |
| etc.) be required to be shut off prior to or during  |        |      |
| work activities?                                     |        |      |
+------------------------------------------------------+--------+------+
| Will work be performed adjacent to or in proximity   | YES    | NO   |
| to any open or exposed electrical equipment,         |        |      |
| conductors, or another craft performing work on such |        |      |
| equipment?                                           |        |      |
+------------------------------------------------------+--------+------+
| Will work be performed on any electrical component   | YES    | NO   |
| or equipment (i.e., work involving installation,     |        |      |
| demolition, modification or testing and analysis of  |        |      |
| electrical equipment or conductors)? **If YES**,     |        |      |
| describe                                             |        |      |
| below:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_                             |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
+------------------------------------------------------+--------+------+
| Have workers been training on NFPA 70E Worker Safety | YES    | NO   |
+------------------------------------------------------+--------+------+
| Will an Electrical Shut Down be required?            | YES    | NO   |
+------------------------------------------------------+--------+------+
| Will an LBNL A1/A2 permit be required?               | YES    | NO   |
+------------------------------------------------------+--------+------+
| LOTO Requirements:                                   | YES    | NO   |
|                                                      |        |      |
| ***Contractor must submit the following items for    | YES    | NO   |
| ALL Utilities to be Shut Off**:*                     |        |      |
|                                                      | YES    | NO   |
| Lock out-Tag-out Program:                            |        |      |
|                                                      | YES    | NO   |
| JHA detailing the scope of work:                     |        |      |
|                                                      |        |      |
| Training Records:                                    |        |      |
|                                                      |        |      |
| Samples/Photos of Company standard locks, tags and   |        |      |
| hardware:                                            |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| List Utilities to be shut off or                     |        |      |
| I                                                    |        |      |
| nterrupted\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| List those persons Qualified to performing this      |        |      |
| work:                                                |        |      |
|                                                      |        |      |
| 1.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\  |        |      |
| _\_\_\_Cert:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| 2.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\  |        |      |
| _\_\_\_Cert:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| 3.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\  |        |      |
| _\_\_\_Cert:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| 4.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\  |        |      |
| _\_\_\_Cert:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| 5.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\  |        |      |
| _\_\_\_Cert:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
+------------------------------------------------------+--------+------+

##  Scaffold/Aerial Lifts

+------------------------------------------------------+--------+------+
| Will Scaffolding or Aerial lifts be used on this     | YES    | NO   |
| project?                                             |        |      |
+------------------------------------------------------+--------+------+
| List type of Scaffold to be used:                    | YES    | NO   |
|                                                      |        |      |
| Tubular & Coupler Scaffolding                        | YES    | NO   |
|                                                      |        |      |
| Rolling Scaffold                                     | YES    | NO   |
|                                                      |        |      |
| Mobile Scaffold                                      | YES    | NO   |
|                                                      |        |      |
| Mason/Bricklayers Scaffold                           | YES    | NO   |
|                                                      |        |      |
| Aerial Lift,                                         | YES    | NO   |
|                                                      |        |      |
| Articulating Boom Lift                               | YES    | NO   |
|                                                      |        |      |
| OTHER:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_       |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Scaffold/Aerial Lifts:***                            |        |      |
|                                                      | YES    | NO   |
| Training Records for each person erecting,           |        |      |
| disassembling scaffold.                              | YES    | NO   |
|                                                      |        |      |
| A Written Fall Protection Plan is required if it is  | YES    | NO   |
| deemed that positive fall protection is infeasible.  |        |      |
|                                                      |        |      |
| Training Records for Fall Protection                 |        |      |
|                                                      |        |      |
| Training Records for "End User" Scaffold             |        |      |
+------------------------------------------------------+--------+------+

## Cranes & Heavy Equipment

+------------------------------------------------------+--------+------+
| Will the work require use of the following           | YES    | NO   |
| equipment?                                           |        |      |
+------------------------------------------------------+--------+------+
| Backhoe, Loader, Excavator                           | YES    | NO   |
+------------------------------------------------------+--------+------+
| Hoist, Man-lift, JLG                                 | YES    | NO   |
+------------------------------------------------------+--------+------+
| Crane Under 3 Tons                                   | YES    | NO   |
+------------------------------------------------------+--------+------+
| Crane Over 3 Tons                                    | YES    | NO   |
+------------------------------------------------------+--------+------+
| Forklift                                             | YES    | NO   |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Crane & Heavy Equipment:***                          |        |      |
|                                                      | YES    | NO   |
| Cranes current annual inspection certification:      |        |      |
|                                                      | YES    | NO   |
| Cranes quadrennial proof load test certification:    |        |      |
|                                                      | YES    | NO   |
| Crane operator license:                              |        |      |
|                                                      |        |      |
| Forklift Certification/License:                      |        |      |
+------------------------------------------------------+--------+------+

## Fire Protection & Prevention

+------------------------------------------------------+--------+------+
| Will work include the use of open flames such as     | YES    | NO   |
| torches, welders, grinders, tar pots or any other    |        |      |
| tool or process/procedure that could cause sparks or |        |      |
| open flames?                                         |        |      |
+------------------------------------------------------+--------+------+
| Will work be performed near combustible storage      | YES    | NO   |
| containers?                                          |        |      |
+------------------------------------------------------+--------+------+
| Will an approved metal safety can onsite for         | YES    | NO   |
| refueling?                                           |        |      |
+------------------------------------------------------+--------+------+
| Has a Burn permit been issued? Contact LBNL Project  | YES    | NO   |
| Manager.                                             |        |      |
+------------------------------------------------------+--------+------+
| Has Fire Watch been trained in the use of Fire       | YES    | NO   |
| Extinguishers and Emergency procedures?              |        |      |
+------------------------------------------------------+--------+------+
| Has the Fire Extinguishers been tagged with their    | YES    | NO   |
| annual servicing? Right size extinguisher(s) within  |        |      |
| the required distance?                               | YES    | NO   |
+------------------------------------------------------+--------+------+

##  Ladders

Title 8 Sub-chapter 4 Construction Safety Orders; Article 25 Ladders
1675 (k) No one shall be permitted to stand and work on the top 3 rungs,
or cleats of a ladder unless there are members of the structure that
provide a firm handhold or the employee is protected by a personal fall
protection system (e.g. positioning device or fall restraint system) in
accordance with the requirements of Article 24 (commencing with section
1669 Fall Protection) of the Cal/OSHA Construction Safety Orders.

+------------------------------------------------------+--------+------+
| Will Ladders be used on this project?                | YES    | NO   |
+------------------------------------------------------+--------+------+
| 6' or smaller A-Frame Ladder                         | YES    | NO   |
+------------------------------------------------------+--------+------+
| 12' or smaller A-Frame Ladder.                       | YES    | NO   |
+------------------------------------------------------+--------+------+
| Extension Ladder under 24'                           | YES    | NO   |
+------------------------------------------------------+--------+------+
| Extension Ladder over 24'                            | YES    | NO   |
+------------------------------------------------------+--------+------+
| Will Fall Protection be required if the scope        | YES    | NO   |
| involves working above 6 feet & above the 3^rd^      |        |      |
| rung?                                                |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following item for     | YES    | NO   |
| Ladders if work above 6'***                          |        |      |
|                                                      |        |      |
| Fall Protection Plan (ANSE/ASSE Z359 included)       |        |      |
+------------------------------------------------------+--------+------+

## Steel Erection and Assembly

+------------------------------------------------------+--------+------+
| Will steel erection be apart of this work scope?     | YES    | NO   |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Steel Erection and Assembly***:                      |        |      |
|                                                      | YES    | NO   |
| A Site-Specific Erection plan                        |        |      |
|                                                      |        |      |
| A Fall Protection Plan (ANSE/ASSE Z359 included)     |        |      |
+------------------------------------------------------+--------+------+

## Roofing Work for ROOFERS (repair, installation of roof)

+------------------------------------------------------+--------+------+
| Will roofing or roof top repairs be performed within | YES    | NO   |
| 6' of the leading edge?                              |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Roofing Work (ROOFERS WORK):***                      |        |      |
|                                                      | YES    | NO   |
| A Fall Protection Plan indicating the fall           |        |      |
| protection system to be used for roofing work 6\' or |        |      |
| more above lower levels and 6\' from an unprotected  |        |      |
| edge. (ANSE/ASSE Z359 included)                      |        |      |
|                                                      |        |      |
| Training Records for all person working on the roof  |        |      |
+------------------------------------------------------+--------+------+

## Fall Protection for NON ROOFERS performing work on roof tops

When working on a flat roof, employees shall remain 15-ft. back from the
edge and use a flag warning system. If the work requires employees to
work within 15-ft. from the edge they will be protected by a fall
protection system.

+------------------------------------------------------+--------+------+
| Will this work scope require non-roofers to work     | YES    | NO   |
| within 15 ft of the leading edge?                    |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Fall Protection for NON ROOFERS***                   |        |      |
|                                                      | YES    | NO   |
| Fall Protection Plan (ANSE/ASSE Z359 included)       |        |      |
|                                                      |        |      |
| Training Records                                     |        |      |
+------------------------------------------------------+--------+------+

# INDUSTRIAL HYGIENE

Hazard Communication/Toxic Substances

  ------------------------------------------------------ -------- -------
  Will the scope of your work require the use of         YES      NO
  hazardous substances? If so, check all that apply               
  below and include requested information.                        

  ------------------------------------------------------ -------- -------

## Hazardous Materials

+------------------------------------------------------+--------+------+
| Will the work involve the use of any chemicals, such | YES    | NO   |
| as paints, solvents, adhesives, epoxy coatings;      |        |      |
| fuels or other hazardous materials?                  |        |      |
+------------------------------------------------------+--------+------+
| Are all personnel using these materials trained in   | YES    | NO   |
| safe handling?                                       |        |      |
+------------------------------------------------------+--------+------+
| Will emergency eyewash and shower be available near  | YES    | NO   |
| the worksite? If NO, provide at a minimum, a         |        |      |
| portable eyewash station that is capable of          |        |      |
| providing 15 minutes of continuous water flow        |        |      |
| (handheld squeeze bottle type is not allowed).       |        |      |
+------------------------------------------------------+--------+------+
| Will employees be exposed to airborne concentrations | YES    | NO   |
| of hazardous gas, fume, dust or mist?                |        |      |
+------------------------------------------------------+--------+------+
| Will employees be exposed to fumes from the use of   | YES    | NO   |
| welding or cutting torches?                          |        |      |
+------------------------------------------------------+--------+------+
| Will Respirators be required?                        | YES    | NO   |
+------------------------------------------------------+--------+------+
| Describe the type of respiratory equipment to be     |        |      |
| used:\_\_\_\_\_\_\_\_\_\_\_                          |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
+------------------------------------------------------+--------+------+

##  {#section-5 .unnumbered}

## Confined Space Entry 

**Confined Space Entry permit are obtained from the LBNL Project
Manager**.

+------------------------------------------------------+--------+------+
| Will the scope of your work require you to be        | YES    | NO   |
| working in a confined space (including manholes)     |        |      |
| where combustible, toxic, or other hazardous         |        |      |
| materials maybe present?                             |        |      |
+------------------------------------------------------+--------+------+
| Will work involve welding, torch cutting, brazing,   | YES    | NO   |
| grit blasting or any machinery use be performed in   |        |      |
| or near confined space?                              |        |      |
+------------------------------------------------------+--------+------+
| Will painting, application of other coatings, or the | YES    | NO   |
| use of chemicals, solvents, combustibles, or similar |        |      |
| hazardous materials be performed in the confined     |        |      |
| space?                                               |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Confined Space Entry:***                             |        |      |
|                                                      | YES    | NO   |
| ***JHA for Confined Space (link)***                  |        |      |
|                                                      | YES    | NO   |
| Sub's Confined Space Program                         |        |      |
|                                                      | YES    | NO   |
| Atmosphere testing records                           |        |      |
|                                                      | YES    | NO   |
| Entry Permits (ongoing submittals)                   |        |      |
|                                                      |        |      |
| Training records                                     |        |      |
+------------------------------------------------------+--------+------+

##  {#section-6 .unnumbered}

##  {#section-7 .unnumbered}

## Welding / Hot Cutting 

+------------------------------------------------------+--------+------+
| Will the work involve welding/cutting steel where    | YES    | NO   |
| lead paint exists or will be abated?                 |        |      |
+------------------------------------------------------+--------+------+
| Will the work involve welding/cutting stainless      | YES    | NO   |
| steel?                                               |        |      |
+------------------------------------------------------+--------+------+
| Will the work involve welding/cutting new            | YES    | NO   |
| construction mild steel?                             |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| non lead related** **(i.e., new steel                |        |      |
| construction)***                                     | YES    | NO   |
|                                                      |        |      |
| Qualitative ½ mask negative pressure respirator fit  | YES    | NO   |
| test records                                         |        |      |
|                                                      | YES    | NO   |
| Medical approval to wear respirators                 |        |      |
|                                                      | YES    | NO   |
| Respirator Program                                   |        |      |
|                                                      | YES    | NO   |
| ***Contractor must submit the following items for    |        |      |
| lead related welding/hot cutting where lead paint    | YES    | NO   |
| exists or has been abated:***                        |        |      |
|                                                      | YES    | NO   |
| Quantitative full face-piece Powered Air Purifying   |        |      |
| Respirator (PAPR) fit test records                   | YES    | NO   |
|                                                      |        |      |
| Medical approval to wear respirators                 | YES    | NO   |
|                                                      |        |      |
| Documentation that workers have received lead        | YES    | NO   |
| awareness training.                                  |        |      |
|                                                      | YES    | NO   |
| Respirator Program                                   |        |      |
|                                                      |        |      |
| Blood lead baseline sample results (excluding        |        |      |
| employee SSNs)                                       |        |      |
|                                                      |        |      |
| ***Contractor must submit the following items for    |        |      |
| stainless steel welding/hot cutting**:*              |        |      |
|                                                      |        |      |
| Quantitative full face-piece negative pressure       |        |      |
| respirator fit test records.                         |        |      |
|                                                      |        |      |
| Medical approval to wear respirators                 |        |      |
|                                                      |        |      |
| Documentation of hexavalent chromium training.       |        |      |
|                                                      |        |      |
| Respirator Program                                   |        |      |
+------------------------------------------------------+--------+------+

## Lead Paint Removal

+------------------------------------------------------+--------+------+
| Will the work involve sanding, grinding, scraping,   | YES    | NO   |
| brazing, cutting, welding, or otherwise disturbing   |        |      |
| painted surfaces in such a way that lead particles   |        |      |
| may become airborne?                                 |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Lead Paint Removal:***                               |        |      |
|                                                      | YES    | NO   |
| JHA that addresses lead hazards                      |        |      |
|                                                      | YES    | NO   |
| Site Specific Lead Compliance Plan                   |        |      |
|                                                      | YES    | NO   |
| Respiratory Protection Program                       |        |      |
|                                                      | YES    | NO   |
| Company's Lead Compliance Program                    |        |      |
|                                                      | YES    | NO   |
| Air Monitoring Data (ongoing submittal item)         |        |      |
|                                                      | YES    | NO   |
| Department of Health Services Lead Worker Training   |        |      |
| Certificates                                         | YES    | NO   |
|                                                      |        |      |
| Full face-piece negative pressure respirator         |        |      |
| quantitative fit test records                        |        |      |
|                                                      |        |      |
| Medical approvals for respirator use                 |        |      |
+------------------------------------------------------+--------+------+

## Asbestos

+------------------------------------------------------+--------+------+
| Will the work require asbestos removal?              | YES    | NO   |
+------------------------------------------------------+--------+------+
| Has a 10 day notification to (BAAQMD) been submitted | YES    | NO   |
| for renovations involving RACM greater than or equal |        |      |
| to 100 linear feet 100 sq ft, or 35 cu ft prior to   |        |      |
| renovations?                                         |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Asbestos***:                                         |        |      |
|                                                      | YES    | NO   |
| Site Specific Asbestos Compliance Plan               |        |      |
|                                                      | YES    | NO   |
| JHA addressing asbestos hazards                      |        |      |
|                                                      | YES    | NO   |
| Respiratory Protection Program                       |        |      |
|                                                      | YES    | NO   |
| Air Monitoring Data (ongoing submittal item)         |        |      |
|                                                      | YES    | NO   |
| Company's Asbestos Program                           |        |      |
|                                                      |        |      |
| AHERA Asbestos Worker Training Certificates          |        |      |
+------------------------------------------------------+--------+------+

##  {#section-8 .unnumbered}

##  {#section-9 .unnumbered}

## Painting Walls

+------------------------------------------------------+--------+------+
| Does the scope of your work include sanding walls    | YES    | NO   |
| and/or ceilings or washing of exterior walls?        |        |      |
+------------------------------------------------------+--------+------+
| Will the work scope involve Spraying painting, Roll  | YES    | NO   |
| etc?                                                 |        |      |
|                                                      | YES    | NO   |
| Ensure workers have Chemical splash goggles (vs.     |        |      |
| safety glasses with side shields) or a face-shield   |        |      |
| over safety glasses with side shields, are required  |        |      |
| for spraying, mixing or other tasks that may create  |        |      |
| splash hazards                                       |        |      |
+------------------------------------------------------+--------+------+
| ***Contractor must submit the following items for    | YES    | NO   |
| Painting Walls***:                                   |        |      |
|                                                      | YES    | NO   |
| JHA detailing the work plan                          |        |      |
|                                                      | YES    | NO   |
| Respiratory Protection Program                       |        |      |
|                                                      | YES    | NO   |
| Qualitative respirator fit test records              |        |      |
|                                                      |        |      |
| Medical approval to wear respirators                 |        |      |
+------------------------------------------------------+--------+------+

##  {#section-10 .unnumbered}

##  {#section-11 .unnumbered}

##  {#section-12 .unnumbered}

##  {#section-13 .unnumbered}

##  {#section-14 .unnumbered}

##  {#section-15 .unnumbered}

##  {#section-16 .unnumbered}

##  {#section-17 .unnumbered}

##  {#section-18 .unnumbered}

## Silica Dust 

+------------------------------------------------------+--------+------+
| Will work involve jack-hammering, roto-hammering,    | YES    | NO   |
| drilling, grinding or other disturbance of concrete  |        |      |
| that might create silica dust? Wet slab/wall         |        |      |
| concrete cutting, drilling, and coring?              |        |      |
+------------------------------------------------------+--------+------+
| Describe below the method of dust control and        | YES    | NO   |
| control of worker and other persons who could be     |        |      |
| exposure, particularly with regards to silica dust   | YES    | NO   |
| generated during concrete or masonry cutting or      |        |      |
| dri                                                  | YES    | NO   |
| lling.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | YES    | NO   |
|                                                      |        |      |
| \_\_\_                                               | YES    | NO   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| ***Contractor must submit the following items Full   |        |      |
| face-piece negative pressure respirators for indoor  |        |      |
| work.(quantitative fit test records).***             |        |      |
|                                                      |        |      |
| ½ mask negative pressure respirators for outdoor     |        |      |
| work (Submit qualitative fit test records)           |        |      |
|                                                      |        |      |
| Medical approvals to wear respirators.               |        |      |
|                                                      |        |      |
| Documentation of silica hazards awareness training.  |        |      |
|                                                      |        |      |
| Respirator Program                                   |        |      |
|                                                      |        |      |
| JHA describing silica hazards                        |        |      |
+------------------------------------------------------+--------+------+

## Heat Stress Program

  ------------------------------------------------------ -------- -------
  Is Heat Stress a potential Hazard for this work?       YES      NO

  Will a rest area be provided in a cooler environment?  YES      NO

  Will the company provide drinking water, cups and      YES      NO
  waste receptacle?                                               

  Has training on recognizing the signs & symptoms of    YES      NO
  heat stress & heat stroke been provided to workers and          
  supervisors?                                                    
  ------------------------------------------------------ -------- -------

##  {#section-19 .unnumbered}

## Ergonomics Program

  ------------------------------------------------------ -------- -------
  Does your company have an Ergonomics Program           YES      NO

  ------------------------------------------------------ -------- -------

##  {#section-20 .unnumbered}

## Sanitation

  ------------------------------------------------------ -------- -------
  Will the company provide washing facilities and        YES      NO
  toilets as required?                                            

  ------------------------------------------------------ -------- -------

##  {#section-21 .unnumbered}

##  {#section-22 .unnumbered}

##  {#section-23 .unnumbered}

##  {#section-24 .unnumbered}

##  {#section-25 .unnumbered}

##  {#section-26 .unnumbered}

## Radiation and Laser Safety

The LBNL Project Manager must be notified one work week in advance and a
radiological work permit must be obtained from the LBNL EH&S Division

+------------------------------------------------------+--------+------+
| Will radioactive material/sources be used?           | YES    | NO   |
+------------------------------------------------------+--------+------+
| Describe                                             |        |      |
| below:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
+------------------------------------------------------+--------+------+
| Will you be working on a class 3B or Class 4 laser   | YES    | NO   |
| or microwave source greater than 5mW/cm2?            |        |      |
+------------------------------------------------------+--------+------+
| Describe                                             |        |      |
| below:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
|                                                      |        |      |
| \_\_\_                                               |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |        |      |
+------------------------------------------------------+--------+------+
|                                                      |        |      |
+------------------------------------------------------+--------+------+

## Storm Water Pollution Prevention Plan

  ------------------------------------------------------ -------- -------
  Will a project specific SWPPP be submitted to LBNL for YES      NO
  review?                                                         

  ------------------------------------------------------ -------- -------

  ------------------ ----------------------------------------------------
  SELLER'S REP       
  (PRINT):           

  SELLER'S           
  SIGNATURE:         

  DATE:              

  PHONE:             
  ------------------ ----------------------------------------------------

+-----------------------------------------------------------------------+
| FOR BERKELEY LAB USE ONLY                                             |
+-----------------------------------------------------------------------+
| ENVIROMENT AND SAFETY HAZARDS CONTROL\                                |
| REVIEW OF CHECK-LIST:                                                 |
+-----------------------------------------------------------------------+
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
| REVIEW STATUS:                                                  |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
| **--Work may proceed.**                                         |   | |
| |                                                                     |
|                                                                 |   | |
| |                                                                     |
| Only the LBNL Construction Safety Engineer, EH&S Safety Manager |   | |
| |                                                                     |
| or designated alternatives may approve Safety Check List        |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
| --**EHS Reviewed with                                           |   | |
| |                                                                     |
| Comments:\_\_\_\_\_\_\_\_\                                      |   | |
| |                                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |   | |
| |                                                                     |
|                                                                 |   | |
| |                                                                     |
| **\_\_\_\_\_\_\_\_                                              |   | |
| |                                                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | |
| |                                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |   | |
| |                                                                     |
|                                                                 |   | |
| |                                                                     |
| **\_\_\_\_\_\_\_\_                                              |   | |
| |                                                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | |
| |                                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |   | |
| |                                                                     |
|                                                                 |   | |
| |                                                                     |
| **\_\_\_\_\_\_\_\_                                              |   | |
| |                                                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | |
| |                                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |   | |
| |                                                                     |
|                                                                 |   | |
| |                                                                     |
| **\_\_\_\_\_\_\_\_                                              |   | |
| |                                                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | |
| |                                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |   | |
| |                                                                     |
|                                                                 |   | |
| |                                                                     |
| **\_\_\_\_\_\_\_\_                                              |   | |
| |                                                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | |
| |                                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |   | |
| |                                                                     |
|                                                                 |   | |
| |                                                                     |
| **\_\_\_\_\_\_\_\_                                              |   | |
| |                                                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | |
| |                                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |   | |
| |                                                                     |
|                                                                 |   | |
| |                                                                     |
| **\_\_\_\_\_\_\_\_                                              |   | |
| |                                                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | |
| |                                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |   | |
| |                                                                     |
|                                                                 |   | |
| |                                                                     |
| **\_\_\_\_\_\_\_\_                                              |   | |
| |                                                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |   | |
| |                                                                     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
| **UNSATISFACTORY - WORK MAY NOT PROCEED**. Provide the          |   | |
| |                                                                     |
| following information: **RE-SUBMIT**                            |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
| |                                                                     |
|                                                                 |   | |
| +-                                                                    |
| ----------------------------------------------------------------+---+ |
+-----------------------------------------------------------------------+
|   ------------------ -----------------------------------------------  |
|   REVIEWED BY EHS:                                                    |
|                                                                       |
|   REVIEWED DATE:                                                      |
|                                                                       |
|   DATE APPROVED                                                       |
|                                                                       |
|   APPROVED BY                                                         |
|                                                                       |
|   CM/PM Approved                                                      |
|   ------------------ -----------------------------------------------  |
+-----------------------------------------------------------------------+

**Construction Sign-in Sheet**

**Name: Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Time:
\_\_\_\_\_\_\_\_\_\_\_\_\_**

**[Print]{.underline} [Signature]{.underline}**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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