# THERMA TRENCH INSPECTION AND ENTRY AUTHORIZATION FORM

| **THERMAL PENETRATION AND ENTRY HISTORIES** |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- |
| LOCATION: |  |  |  |  | JOB #: | DATE: |  |
| TIME OF INSPECTION: |  |  |  |  | USAN#: |  |  |
| WEATHER CONDITIONS: |  |  | OSHA NOTIFICATION: |  | Yes No | TEMP.: |  |
| SUPERVISOR: |  |  |  |  | COMPETENT PERSON: |  |  |
| DIMENSIONS: | DEPTH = |  |  |  | Yes No HAZARDOUS CONDITIONS |  |  |
|  | TOP = W |  | L |  | □ □ Saturated soil / standing or seeping water |  |  |
|  | BOTTOM = W |  | L |  | □ □ Cracked or fissured wall(s) |  |  |
| SOIL TYPE: |  | TESTED: |  | □ □ Bulging wall(s) |  |  |  |
| Type A Solid rock (most stable) |  | □ Yes □ No |  | □ □ Floor heaving |  |  |  |
| Type B |  | □ Thumb |  | □ □ Utilities Supported |  |  |  |
| Type C (loose sand or fill) |  | □ Penetrometer |  | □ □ Super-imposed loads |  |  |  |
| Previously Disturbed |  |  |  | □ □ Vibration Near Excavation |  |  |  |
| Cohesive Non-cohesive |  |  |  | □ □ Ventilation Required |  |  |  |
| **PROTECTION METHODS:(Walls MUST be vertical—NO voids)** |  |  |  | **PLACEMENT OF SPOILS & EQUIPMENT** |  |  |  |
| SHORING |  |  |  | □ □ Spoils at least 2 feet from edge of trench |  |  |  |
| Timber |  |  |  | □ □ Subject to surcharge from equipment |  |  |  |
| Pneumatic |  |  |  | □ □ Backhoe at end of trench |  |  |  |
| Hydraulic |  |  |  | □ □ Compressor, etc. at remote location |  |  |  |
| Screw Jacks |  |  |  | **LADDER LOCATION** |  |  |  |
|  |  |  |  | □ □ Located in protected area |  |  |  |
|  |  |  |  | □ □ Within 25 feet of safe travel |  |  |  |
| **SHIELDING / SLOPING or BENCHING** |  |  |  | □ □ Secured |  |  |  |
| Trench Box |  |  |  | □ □ Extends 36 inches above the landing |  |  |  |
| Sloping/Bench: B 1:1 (45°) C 1½:1 (34°) |  |  |  | □ □ Leads to safe landing |  |  |  |
| Yes No **ENVIRONMENTAL CONDITIONS:** |  |  |  | **OTHER:** |  |  |  |
| □ Air Monitor used? |  |  |  | □ Shoring equipment inspected prior to use? |  |  |  |
| □ Confined space permit issued? |  |  |  | □ Is trench SAFE to enter? |  |  |  |
| DATE | INSPECTED BY: |  | INITIALS | DATE | INSPECTED BY: |  | INITIALS |
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| **NOTE:** All unsafe conditions must be corrected prior to trench entry. If any hazardous conditions are observed, the trench must be immediately evacuated and no one allowed to re-enter until corrective action has been taken. |  |  |  | **ENTRY AUTHORIZED BY:(COMPETENT PERSON)** |  |  |  |