Date
02/26/2026
Time
07:50 AM
Employee First & Last Name
Seth Doty
Job
Steuben
Atmosphere tested - O2
20.3
Atmosphere tested - CO
O
Atmosphere tested - LEL
O
Atmosphere tested - H2S
O
Excavation Depth
3’
Soil Class
C (0.5sf or less)
Have locates to the "811" One Call System been made?
Satisfactory
Are locates active?
Satisfactory
Hand dig in the tolerance zones, 24” for IN. 48” for MI. plus ½ of the pipe utility size:
Satisfactory
Maintain 10' separation to all overhead power lines:
Satisfactory
Utility spotter to help find all buried facilities, and maintain 10' separation on overhead:
Satisfactory
Trench Box
Not applicable
Trench Boxes On-Site:
001
Sloping
Satisfactory
Shoring
Not applicable
Accumulating water being removed:
Not applicable
Excavation inspected after a rainstorm:
Not applicable
Excavator inspection forms complete:
Satisfactory
All employee's trained in excavation:
Satisfactory
Bottom of the box is within 2' of the bottom of the excavation:
Not applicable
Employees are protected from rolling or falling objects into the excavation:
Satisfactory
Ladder in good shape, being used in excavation 4' or deeper, within 25' of employees:
Satisfactory
Spoil pile back at least 2':
Satisfactory
Undermined structures supported: (utilities, sidewalks, buildings, curbs)
Satisfactory
No one within 5' of swing radius of the excavator:
Not applicable
Unattended or left open excavation is protected with snow fence and barricades:
Not applicable
Employees wearing proper PPE: (hardhat, class II vest, gloves, safety glasses, safety toe)
Satisfactory
Operator's wearing seatbelts, all equipment is equipped with ROPS:
Satisfactory
Fire extinguisher in the cab and properly secured:
Satisfactory
Back-up & travel alarms are working on all equipment:
Satisfactory
No cracked glass on any equipment:
Satisfactory
All rigging equipment in good shape and has a certified tag or label:
Satisfactory
Signature
Employee First & Last Name
Seth Doty