Doc No: BK9A-GEN-000-HSE-CRT-0002 Rev: A

Certificate No. EXCAVATION CERTIFICATE

VALID FOR THE DURATION OF THE PRIMARY WORK PERMIT ONLY
Location of Work:

Date: __________________
Time: __________________

Soil Classification Type Brief description and reason for excavation: Connected PTW/Certificate No.
Class A
Class B
Class C
Length x Width x Depth of Excavation: _______ mtr. X _______ mtr. X _______ mtr.
Means of Protection: Sloping/Benching: Angle of slope/bench: ________ degrees,
(Attach details/sketch) Shoring:
Shielding:
Site plan attached
Means of Excavation: Manual: Site as-built drawing attached
Mechanical:
Dewatering required: Means of dewatering: ________________ Excavation drawing attached
Soil compaction required Degree if compaction: ________________ % Protection sketch attached
Yes No Compaction details attached
Period during which excavation will remain open: From ..................... Date until ............ Date
Area barrication through: Cordon Rope,
Yes No tape Fence Manual guarding TRA attached
External Agency Certificates attached

List of heavy equipment to be used: Hazards Identified and addressed

Subsoil Water
Subsoil/runoff water disposal/diversion
Underground wires, cables
Underground pipes
Method and design of protection against cave-in: Underground sewers
Additional lighting requirement
Road digging involved
Water way crossing involved
Exit ladder/steps every 25 mtr.
Spoils, material, equip set off 1 mtr. from edge
Means of Dewatering, water disposal and diversion: Oxygen deficiency
Presence of Flammable/Toxics
Ventilation Requirements
Gas Testing requirements
Exposure to vehicular traffic
Additional requirements in case excavation is a Confined Space: Adequate barrication/sign posts
Overnight protection/guard
Road Closure required
Personal Fall Arrest System
Emergency rescue/Retrieval System
Additional PPE requirements: Others (Specify)

Ensure all excavation equipment and accessories have been inspected before use.
Mechanical excavation is not allowed inside process facilities or within 10 ft. of existing flow lines/ instrument - electrical cables etc.

Excavation Certificate prepared by (Name and Signature): _____________________________ _____________________________

Excavation Certificate reviewed by (Name and Signature): _____________________________ _____________________________

Excavation Certificate approved by (Name and Signature): _____________________________ _____________________________

Original : Performing Authority: Copy1: Permit to Work Station: Copy 2: CoW Office: