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TITLE: Site Specific Safety PlanProject Number:Project Title:Subcontractor Name:Date:Page 1 of 12Site Specific Safety Plan Procedure FormUpdated 10.17.14Procedure Intent:This procedure will:1. Help identify and document EHS (Environmental, Health, and Safety) issues and/or concerns in the projectspecifications/bidding process so that Subcontractors will be prepared to provide Contractor with a specific SiteSpecific Safety Plan. The advantages are:a.Open communications between Contractor site representatives and Subcontractors regarding the potential safetyhazards well in advance of job/task executionb.Subcontractor will be informed of Contractor’s EHS expectationsc.Any associated costs for EHS compliance issues will be captured ahead.Intended Output:The Subcontractor will provide Contractor with a written Site Specific Safety Plan using the attached Site Specific SafetyPlan Form that will document how the Subcontractor will address any anticipated and/or recognized hazards associatedwith their project/contract work. This is an important step in the communication process to promote open communicationbetween the Service provider/Subcontractor and Contractor.Contractor Life Saving Commitments Program:Contractor has developed the Life Saving Commitments program which focuses on eliminating serious injury and death onthe job site. This program identifies eight of the most prevalent high-hazard activities, or “commitments”, encountered onContractor projects. Sections pertaining to any of the eight commitments in the Site Specific Safety Plan are labeled with thecorresponding Life Saving Commitment symbol and highlighted in orange.#1: StoredEnergy#2: FallProtection#3: Cranes &Rigging#4: ConfinedSpaces#5:Excavations#6: MobileEquipmentA Site Specific Safety Plan shall be completed and submitted for all field work performed.#7: Caught-in/ Struck-by#8: Drugs &Alcohol

TITLE: Site Specific Safety PlanProject Number:Project Title:Subcontractor Name:Date:Page 2 of 12Site Specific Safety Plan FormThe Contractor project manager/requestor/etc. should assist the Subcontractor in completing this form.Use the Contractor Subcontractor Safety Program Document as a reference and resource and consult with the ContractorEHS Department.All required signatures must be obtained by t h e S u b c o n t r a c t o rand/or C o n t r a c t o r projectmanager/requestor/etc. prior to submittal. The completed form must be submitted to and approved by the Contractor EHSPRIOR to ANY work taking place.NAME OF PROJECT/WORK:DATE:PROJECT/WORK LOCATION:PROJECT #:CONTRACTOR E:CONTRACTOR FOREMAN:PHONE:NAME OF SUBCONTRACTOR TOCONTRACTOR:PREPARED BY:PHONE:EMAIL:SUBCONTRACTOR SAFETY REP:PHONE:EMAIL:NAME OF SUBCONTRACTOR TOSUBCONTRACTOR:PREPARED BY:PHONE:

TITLE: Site Specific Safety PlanProject Number:Project Title:Subcontractor Name:Date:BRIEF SCOPE/ DESCRIPTION OF PROJECT/WORK:Emergency Evacuation Plan and Location (to be determined by Contractor Site Supervision):Page 3 of 12

TITLE: Site Specific Safety PlanProject Number:Project Title:Subcontractor Name:Date:Page 4 of 12LIFE SAVING COMMITMENTS#1: STORED ENERGYSUBJECTREQUIREDYESNON/A LOCKOUT / TAGOUT (LOTO):Will LOTO be required? Are LOTO procedures available?Has a responsible person been assigned foroverseeing LOTO requirements? SUBJECTREQUIREDYESNOPIPE AND VESSEL PRESSURE TESTING:N/A Will any pipe/vessel pressure testing berequired? Will pipe/vessel testing be performed withindesign specifications?Has Pressure Testing Safety Plan beendeveloped and approved in accordance withthe Stored Energy Procedure? **NOTE: All Pressure Testing Safety Plans will besubmitted to Project Management Team forapproval. EHS will review as needed. Hydrostaticis the preferred testing method. **NOTE: Hydrostatic testing is Contractor'spreferred testing medium.SUBJECTSpecific & detailed information / descriptionrequired for all questions.REQUIREDYESNOIf yes, Contractor Superintendent will inspectLOTO source and ensure LOTO proceduresare followed.Specific & detailed information / descriptionrequired for all questions.Specific & detailed information / descriptionrequired for all questions.N/A COMPRESSED GAS:Will cylinders be brought on site? Are there plans for safe use and storageon site? Type of cylinders and quantity:

TITLE: Site Specific Safety PlanProject Number:Project Title:Subcontractor Name:Date:Page 5 of 12LIFE SAVING COMMITMENTS#2: FALL PROTECTIONSUBJECTREQUIREDYESNON/A LADDERS / SCAFFOLDING:Will ladders be required? (All Ladders - min300 lb rating.) Metal ladders will be approved by ContractorSuperintendents.Provide Competent Person(s) name, contactinformation and training verification.Will scaffolding be required? (Scaffold Tagsand inspections are required per Contractorpolicy.) Will fall protection be required? Listequipment to be used. SUBJECTREQUIREDYESNOFALL PROTECTION, LEADING EDGEWORK, ELEVATED SURFACES (no safetymonitors):N/A Has a Fall Protection Rescue Plan beendeveloped? Attach and describe plan. Will fall protection be required? (Nosafety monitors.) 100% protection 6feet Are competent/qualified personsidentified to perform system andequipment inspections, identify hazards,and anchor points as needed?SUBJECTSpecific & detailed information / descriptionrequired for all questions. REQUIREDYESNOSpecific & detailed information / descriptionrequired for all questions.Systems to be used:Provide Competent Person(s) name andcontact information.Specific & detailed information / descriptionrequired for all questions.N/A ROOF WORK (no safety monitors):Will roof access be required? Is there a plan to get materials on/off roofin place? Has a method for securing materials toprevent "blow offs" been identified? Are chemicals or flammable /combustible materials going on roof? Attach Fall Protection Plan and EmergencyRescue Plan (primary and alternate) (to besubmitted prior to work).Approved by:

TITLE: Site Specific Safety PlanProject Number:Project Title:Subcontractor Name:Date:Page 6 of 12LIFE SAVING COMMITMENTS#3: CRANES & RIGGINGREQUIREDYESNOSUBJECTSpecific & detailed information / descriptionrequired for all questions.N/A CRANES AND RIGGING:Will crane operations be required?**NOTE: If yes, all crane plans will bereviewed by Regional Safety Manager 1 weekprior to the lift. Have all overhead lines been identifiedand the locations appropriatelycommunicated? Will any special lifting devices be needed? Will any Critical Lifts take place?Attach crane lift plan, operator, rigger andrdsignaler verification of training. Provide 3 partyannual inspections.Attach and describe critical lift plan and activity.**Note: Contractor defines a Critical Lift asmeeting any of the following criteria: 1)exceeds 75% of the capacity of the crane orderrick; 2) requires more than one crane orderrick; or 3) involves lifts over people or criticalwork processes. Has all rigging equipment been inspected? Is all equipment appropriate for the task(s)? Have all required safety inspections beencompleted? Will traffic control be provided (pedestrian &vehicular)? Attach verification of training (to be submittedprior to work).Inspection logs completed for equipment/liftdevices.Attach flaggers’ names / training (2 minimum).LIFE SAVING COMMITMENTS#4: CONFINED SPACESSUBJECTREQUIREDYESNON/A CONFINED SPACES:Will any confined space work be performed?**NOTE: Atmospheric testing must be conducteddaily prior to entry into a Confined Space. Will any Confined Space Entry permits berequired?Have affected personnel been trained forconfined space entry? Specific & detailed information / descriptionrequired for all questions.

TITLE: Site Specific Safety PlanProject Number:Project Title:Subcontractor Name:Date:Page 7 of 12REQUIREDYESNOSUBJECTWill external rescue team services to beused? Please specify the name of theprovider. Have all entry procedures been provided anddocumented? Specific & detailed information / descriptionrequired for all questions.Attach Confined Space Plan (submitted prior towork).LIFE SAVING COMMITMENTS#5: EXCAVATIONSREQUIREDYESNOSUBJECTSpecific & detailed information / descriptionrequired for all questions.N/A EXCAVATIONS (all soil type is C):Will equipment to be brought on site? Pleasespecify type. Will any work activities involve excavationsgreater than four feet? Will a trench box/shoring be needed?Does fencing/barricade need to be installed? Provide Competent Person name, contact infoand training verification.LIFE SAVING COMMITMENTS#6: MOBILE EQUIPMENTSUBJECTREQUIREDYESNOMOBILE EQUIPMENT / POWEREDINDUSTRIAL FORK TRUCKS / LIFTS /BOOMS:Specific & detailed information / descriptionrequired for all questions.N/A If yes, keep daily/shift inspection logs on theequipment.Will any mobile powered equipment berequired? Type to be brought on site? Will you be using any specialattachments? ex. jibs, manlifts, etc. Are operators trained / certified foroperations of equipment? Attach verification of training (to be submittedprior to work).Is there a plan for fuel transfer/storage orbattery changes? Spill kit/containment pad required containing80% equipment capacity.

TITLE: Site Specific Safety PlanProject Number:Project Title:Subcontractor Name:Date:Page 8 of 12LIFE SAVING COMMITMENTS#7: CAUGHT-IN/STRUCK-BYSUBJECTREQUIREDYESNON/A CAUGHT-IN / STRUCK-BY HAZARDS:Are employees familiar with pinching andcrushing points? Are special precautions taken whenworking around belts, pulleys, chains,etc.? Are employees aware of the hazardsassociated with overhead loads andswing radius? Are all vehicles equipped withappropriate back-up alarms, horns andlights? SUBJECTREQUIREDYESNOSpecific & detailed information / descriptionrequired for all questions.N/A POWDER ACTUATED TOOLS:Are operators/employees trained /licensed in use?Specific & detailed information / descriptionrequired for all questions. Attach verification (submitted prior to work).LIFE SAVING COMMITMENTS#8: NO DRUGS OR ALCOHOLIn accordance with the Subcontractor Safety Responsibilities document, subcontractors must agree to adhere to theContractor Drug and Alcohol policy. Drugs and alcohol are strictly forbidden from all Contractor jobsites.

TITLE: Site Specific Safety PlanProject Number:Project Title:Subcontractor Name:Date:Page 9 of 12Additional Focus Areas:SUBJECTREQUIREDYESNOSpecific & detailed information / descriptionrequired for all questions.PERSONAL PROTECTIVE EQUIPMENTWhat type of PPE will be used for thisproject? Will any special PPE be required, i.e.respirators? What type? Have eye wash and shower stations beenset up on the jobsite?Has personnel received training for specialPPE requirements? NOTE: Hi Vis (yellowshirt) clothing is required. Is there verification of medical respiratoryprotection clearance submitted / attached? Will respirators be worn on a voluntary use?(Half mask, paper, etc.) Is a de-con area required for suitingup/down? SUBJECTREQUIREDYESNOAttach Respiratory Protection Plan:Subcontractor to maintain copy on site.Attach Appendix D for each employee.Specific & detailed information / descriptionrequired for all questions.SIGNS, SIGNALS AND BARRICADES:N/A Will yellow or red barricade tape be used?(Barricades will be built in accordance withContractor policy) Will perimeter barricades be used? Will any caution/danger signs be needed? Will flammable gas/liquid labels be needed?Will material labels be needed? GHS SUBJECTREQUIREDYESNOSpecific & detailed information / descriptionrequired for all questions.N/A WORK PERMITS:Will any pipe or vessel testingpermits be required? Will any excavation permits berequired? Will any utility interruption permits berequired? Will Hot Work (welding/cutting/grinding/soldering/electrical) permits be required?Will any lead/asbestos permits be required? Attach Plan.