EXCAVATION CERTIFICATE

Certificate No. : EXC- Edisi/Revisi : 01/00

Section 1 - Application (Completed by the Permit Applicant)

Name : Ref ID / : Department :

Position / Company

Signature : Date :

Location of Work : Associated Permits :

Site :

Section 2 - Detail of the Excavation (Attach As-Built Drawing showing limits of the excavation work to this Certificate)

Section 3 - Detail of the Existing Underground Services near the Excavation Work (Attach As-Built Drawing showing limits of the
excavation work to this Certificate)

Section 4 - Departmental Approval (Responsible Supervisor to nominate Departments that require to be consulted. Nominated
departments complete required information below)
Department / Division
Nominated Remarks / Conditions / Observations Name / Signature Ref ID Position Date

Telecom/IT

Electrical

Instruments

Pipelines

Survey

Section 5 - Precautions (Completed by the Responsible Supervisor/Operation Authority/HSSE)

Other Precautions
€ O Cable detector to be used over proposed route € O
€ O Pilot trenches to be hand dug to locate services € O
€ O Excavation may be carried out by mechanical means after pilot € O
trenches are completed, but no closer than 1M from the services
€ O
€ O When excavation rock, any soft areas to be checked to ensure € O
they are not trenches for other services

€ O Banksman/Rigger/Watchman to be provided

Section 6 - Authorizations (Completed by the Responsible Supervisor)

I authorise the excavation work specified above to be carried out, subject to the above precautions being enforced and maintained, during the
validity period of the covering Permit to Work/No Permit Certificate for the work specified in Section 1 of this form.

Name : Ref ID :
Signature : Date :
Expiry date :

NOTE : This certificate is valid for the scope defined in Section 02 (including the supporting drawings). The certificate may be used to support sub sequent permits
etc, provided the scope or any associated risks do not change.

Section 7 - Acceptance (Completed by the Permit Holder)

I understand the cotent of this certificate and shall ensure that all work is undertaken in accordance with the instruction stated and in accordance
with any other mandatory governing procedure(s) that are/is in affect.

Name : Ref ID/Position :

Signature : Date :