D
Excavation Certificate
Location ______________________________
Valid only when attached to Permit
to Work No.
(Only to be completed by authorised persons)
Digging instructions to the permit applicant
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Piping and electrical/instruments must be localised by hand digging (with spades).
Identified cabling and piping must be marked with wooden pegs or spray paint.
Piping and Cabling may have moved from its original location, as indicated on as-built drawings, due to soil settlement.
Within 1-meter radius around piping and cabling, only hand digging with spades may be used.
Excavations deeper than 1.2 meters require slopes of max. 70 degrees or side supporting structures to prevent collapse.
Use of digging machinery is allowed: Yes / No (a gas Test Certificate – Hot work is required).
Exposed piping and cabling to be supported.
Workers maintain safe distance while equipment is in operation.
Spoil pile must be minimum 0.75 meters from the edge of the excavation
Excavations 6 meters or deeper require the services of a specialized Engineer
The handling of contaminated soil requires the use of PPE as defined on the Permit to Work
Work at Height policy to be complied with.
I have checked the site / studied the layout drawings and certify that the excavation proposed under Permit to Work
number_________________ dated _________________ can be carried out:
a)
* Without risk of damage to any underground services
b)
* Provided that the following additional precautions are taken to prevent damages to the equipment/services specified
below:
Situation Sketch / Indication of Hazards:
Validity of the Excavation Permit
PI: I certify that I have reviewed the proposed
work and I am satisfied that it is adequately
described on the Permit to Work documents
and that the precautions detailed in this
certificate are adequate and clearly defined.
The Permit to Work is allowed between:
Permit Holder
Excavation work certificate and
Permit to Work are withdrawn
From:
Time:
Until:
Reason:
Name:
I certify that I am aware of the
planned work and the precautions
detailed on the Permit documents and
will ensure that work only proceeds
when the conditions set out in the
documentation are met
Signature:
Signature:
Signature:
Date/Time:
Date:
Date:
Form D – Excavation
Certificate
Permit to Work System
Version 1.1
December 2011
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