EXCAVATION PERMIT
This Permit is Required for ALL Excavation, Digging, Soil Removal, or Ground Disturbance on Pfizer Property
EMERGENCY EXCAVATIONS: Contact the Contractor Safety Representative and the CM / CAS Responsible for the area and execute the
permit in the safest possible manner.
1. Job Description & Contacts
Contractor / Requestor:
Pfizer Contact: CM / CAS:
Start Date:
______________
Est. Completion:
___________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
Phone:
CM / CAS: Review Site / Utility Drawings Complete
___________________________________
n/a
__________________________________________________________
Location:
CAPITAL PROJECT
_______________________________________________________________________________________________________________________________
MAINTENANCE
Describe Scope of Work:
________________________________________________________________________________ __________________
IFM
_______________________________________________________________________________________________________________________________________________________
2. Pre-Excavation: Identifying Underground Hazards
Contact the following individuals to review underground utilities / services and soil conditions in planned excavations
Complete
n/a
n/a
n/a
n/a
n/a
n/a
Area
Soil Management
Communications, phone, fiber optic’s etc.
Electrical Systems
Water Department
Fire Protection Systems
Trestles and Utilities Systems
n/a
Miss Dig: right of way or easement
3. Underground Utility Verification:
Required
Contact Name
Bill Hunsberger
Pat Vanderbush
Jim Taylor
Frank Robinson
Jim Miles
Andrew Redlon
Phone
(269)217-8125
(269)806-9817
(269)744-4255
(269)998-1739
(269)720-5181
(269)760-0621
Comments
Miss Dig
(800)482-7171
N/A This section may be omitted for Emergency and/or Hand Dig Excavations
Complete
Task
Pre-surveying review: Surveyor and Excavation Company
Ground Penetrating Radar (GPR) has been Conducted
Radio Frequency Testing has been Conducted
All utilities marked per APW Uniform Color Codes
Post survey review: Surveyor, CM /CAS and Excavation Company prior to executing work.
Excavation equipment operator has reviewed the survey results
Surveyor Technician:
Print Name:
Surveyor Company:
Signature:
Date:
4. Excavation Requirements
Excavation Company:
Excavation Company Safety Representative:
______________________________________________________________________________________________
Qualified Person:
__________________________________________________________________________________________________________
*Inspect Excavation Daily
*Ensure Safe Conditions
Ensure Safe Conditions
Name:
_______________________________________________________________________________________________________________________________
Phone:
______________________________________
Excavation Support:
Excavation is less than 4’ deep (shoring not required)
Trench Box
Engineered Shoring System
Field Designed Shoring System
Sloping / Benching
Excavation Equipment:
Yes n/a
Mechanical Equipment Used:
Hand Dig / Hydro Excavate to Expose Utilities
 Pot holing required within 2ft of identified utility
 No dry vacuum allowed due to static electricity
Probe – probe depth must exceed soil layer to be removed
Auger (fencepost, etc.)
Version 12 – December 2015
Changes in vehicular traffic or road closings may require
a site notification. Contact the following:
Fire Station: (269)833-5122
Transportation: (269)833-3767
Security: (269)833-3636
Excavation Type:
Hand Dig
Saw Cut / Core Drill
Auger
Mechanical Dig
Hydro excavate
5. Excavation Hazard Identification - Check and Review Daily – This Section Must be Completed in the Field
Excavation Type:
Complete this section during the excavation process. Refer to
MIOSHA regulation R 408 Part 9 to determine trenching and/or
excavation requirements pertaining to sloping, shoring, and angle of repose.
Initial Soil Test :
Date: ______________
Angle of Repose:
1:1
1½:1
2:1
Soil Type:
______________________________________________________________________________________________________________
Change in Soil Condition:
Date:
______________________________
Soil Type:
______________________________________________________________________________________________________________
Change in Soil Condition:
Date:
______________________________
Soil Type:
______________________________________________________________________________________________________________
Change in Soil Condition:
Date:
______________________________
Soil Type:
______________________________________________________________________________________________________________
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
Electrical and/or Overhead Hazards:
 Equipment and personnel are kept a minimum of 10' or greater away from overhead electrical lines.
 Overhead electrical systems identified and signage of Hazard shall be posted.
Other known hazards (i.e. Trestles, Footings, Concrete encasements, roadways and sidewalks)
______________________________________________________________________________
Utility / Services Marking and Identification:
 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, Barricades, Signs
 Hard barricades or snow fence required. (No Barrier Tape for overnight use)
 Display “Danger – Open Excavation” signs with contact information
 Barricades and signs must conform to MIOSHA regulations
Egress within Trench or Excavation > 4’ deep
 No more than 25’ of lateral travel is allowed for workers to Egress
o Ladder: Must extend 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 angle of the ramp shall not be more than 45 degrees
c) Vertical height between the floor of the trench and the toe of the ramp shall not exceed 30 inches
Backfill Requirements
 All soil removed from the excavation must remain on-site and have Pfizer approval for backfill
 Foil 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 exist
6. Excavation Permit Approval:
Approvers
Print Name
Sign for Approval
Date
Qualified Person:
Pfizer Representative (CAS / CM)
EHS Representative
Approved Excavation Permit
Requestor: E-mail to the following
managers:
Ray Pogliano
Tom L. Fletcher
Bruce S. Howard
Jim Ledden
7. Permit Completion:
Construction Manager
CM / CAS:
Excavation is backfilled and job is complete.
Retain Excavation Permit with project file.
Version 12 – December 2015
raymond.a.pogliano@pfizer.com
thomas.l.fletcher@pfizer.com
bruce.s.howard@pfizer.com
james.a.ledden@pfizer.com
Print Name
Sign
Date
n/a
Daily Inspection Log
Ongoing inspections of all excavations or trenches shall be made by a Qualified Person.
If hazardous conditions are found, all work within the excavation must stop until unsafe conditions are abated.
Qualified Person: Verify Excavation has been Inspected and is Safe to Enter
Atmospheric Test Requirements
 Use the Safe Work Permit to record all atmospheric testing results
 Atmospheric Testing is required when excavations are ≥ 4ft. in depth
 Conduct Atmospheric Testing no earlier than ½ hour before entering the excavation
 Retest is required if Excavation is left unattended
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Contracted Supplier(s) Working in Excavation
All suppliers working in this excavation have read and will adhere to the requirements of the Excavation Permit.
The Competent Person signed below confirms that all workers entering the excavation have received excavation training from their
employer.
Additional Suppliers Working in Excavation
(Supplier Name)
Version 12 – December 2015
Competent Person
Print Name
Trade Type,
(Electrical,
Piping,
Etc.)
Competent Person
Signature
Date