TEAR OFF PORTION

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TransAmerican Underground, Ltd.
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1904 Peninsula Drive
Job Safety Analysis (JSA) Checklist
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Flower Mound, Texas 75022
Date:
TAUG Crew: Facility/Well Name
Meeting Place in Case of an Emergency GPS Coords for EMERGENCIES
Contractor Contact
Job# or Description of work
to be performed
Designated Smoking Area Location
Safety Equipment Required to Do This Job
Hard Hat Face Shields/Goggkes Fire Extinguishers Gas Dectetor Other (list)
Steel Toed Boots Cotton/Rubber Gloves Ground Static Cable First Aid Kit
Safety Glasses Rubber Boots & Apron Wheel Chocks Eye Wash
Coveralls (FR) Safety Harness/Anti-fall Device Lockout/Tagout SCBA
Hearing Protection Rescue Lanyard & Rope Communications MSDS on site

Pre-Job Hazard Assessment

Lifting Hazards Body Position/Movement
Manual Lifting (Body Position) Y N Proper Tool/Material Placement Y N Climbing Y N
Mechanical Lifiting Equipment Y N Hot/Cold Surface or Material Y N Pulling, Pushing Y N
Awkward Body Position Y N Inadequate Lighting Y N Bending Y N
Slip/Trip Potential Y N Fall Protection/Anchor Points Y N Twisting Motion Y N
Lifting w/Other Employees Y N Pinch Points Y N Walking Y N
Proper Rigging Practices Y N Hand & Finger Hazards Y N Crawling Y N
Electrical Hazards Y N Straining Y N
Access/Exit Welding/Flame Cutting Y N Stretching Y N
Handrails Placement Y N Mechanical Equipment Y N Reaching Y N
Ladders/Stair Rails Placement Y N Drill Rod Loading Y N Over Extending Y N
Barricades Placed Y N Are all containers properly labeled? Y N
Secure Footing Y N Hot Work Permit
Evacuation Routes Identified Y N Is a Hot Work Permit Required?
Y N
Confined Space Permit If Yes - Follow Chesapeake Hot Work
Does work involve Confined Space Entry? Policy
Y N Excavation/Trenching/Drilling
If Yes- Follow Chesapeake Confined Space Policy Y N Lockout Tagout (LOTO)
Does work involve excavation, trenching,
drilling etc? Does work require lockout tagout?
Work Plan Has One Call Notification been made? Y N Y N
Has a Work Plan been developed? One Call Notification # Person Responsible for LOTO
Y N One Call Notification Date
If yes attach JSA to work plan Note: Must wait 48 hours after notificatioation before excavation, trenchinching or drilling
Potential At-Risk Behaviors or Other Action Taken to Eliminate or Reduce
Sequence of Basic Job Steps Potential Hand and/or Finger Hazards
Hazards Potential Hazards

Environmental Conditions
Day Night Clear Fog Drizzle Humid Rain Snow Ice Dust Lightning

Temperature 0 Degrees or Less 0 to 32 Degrees 32 to 80 Degrees 80 Degrees or Higher

Winds Mud
15 MPH or Less 15-40 MPH 40 MPH or Higher Dried Moderate Deep
Surrounding Area Use Commercial Industrial Residential Farm/Ranch Other
Supervision Availability Location Type of Job Work Area Communication During Task
None on Location Elevated Routine Open Written
Intermittent Below Ground Level Medium Tight Verbal
Foreman/Pusher Confined Space Complex Congested Hand Signal
On Location Ground Level Intrinsically Safe Radio
Other Service Companies on Location

Crew Members, Company Representatives & Third Party Signatures

I have personally inspected the worksite & confirm that it is safe for the work described (To be completed by the Responsible Person on the job site)

Authorized Signature Print Name

NOTE: Back side of form can be used for additional names