CONFINED SPACE EVALUATION

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SECTION I GENERAL INFORMATION Permit Number: Date/Time: Expires at:

LOTO Permit Number: Confined Space Name / I.D. #:

Location / Description of Space:

Purpose of Entry:

SECTION II CHECKLIST When completing the Checklist below, consider the potential hazards and conditions within the space prior to entry, as well as hazards that may be introduced by entrants and/or their work within the space.

(A) Is the space isolated?

(B) Surrounding area free of hazards such as drifting vapors, gases, hot work, etc.?

(C) Have all engulfment hazards been isolated through; blanking or blinding; misaligning or removing sections of lines, pipes, or ducts; or adouble block and bleed system?

(D) Have all mechanical, pneumatic, gravitational, hydraulic, and/or exposed electrical hazards been eliminated through LOTO?

(E) Are initial atmospheric readings within acceptable limits listed below?

(F) Is there a configuration hazard present that could entrap an entrant?

(G) Does the entrant need outside assistance to access/egress the space?

(H) Does the space contain chemical and/or material contents or residues that could endanger an entrant through contact or burial?

(I) Does the space contain any other serious safety or health hazard?

(J) Does the space contain, or have the potential to contain, atmospheric hazards that require respiratory protection beyond nuisancedusts?

(K) If YES to (J) above, can the potential hazardous atmosphere be controlled via continuous forced air ventilation?

SECTION III INITIAL ATMOSPHERIC TESTING Pre-entry test performed by: Meter: Calibration check date:

Oxygen Flammability CO H2S SO2 ___________ Acceptable: 19.5% to 23.5% < 10% LEL < 35PPM < 10 PPM < 5PPM ___________

Pre-entry: ___________ ___________ ___________ ___________ ___________ ___________

SECTION IV ENTRY PROTOCOL This section is a determination of the minimum Entry Protocol that must be used for the designated space under the entry purpose and conditions stated. The Entry Supervisor may upgrade any entry to Permit Required, at his or her discretion, but may NEVER downgrade an entry to a Protocol not clearly supported by the information provided on this Evaluation.

Non-permit Required Entry 1) Section II, (A) – (E) are checked YES2) Section II, (F) – (J) are checked NO

Alternate Entry Procedures 1) Section II, (A) – (E) are checked YES2) Section II, (F) – (I) are checked NO3) Section II, (J) is checked YES AND (K) is checked YES

Permit Required Entry 1) Section II, (A) – (E) any are checked NO2) Section II, (F) – (I) any are checked YES3) Section II, (J) is checked YES AND (K) is checked NO

NAME: _________________________ SIGNATURE: __________________________________ DATE: __________________

ENTRY PERMIT SPACE CONFINED

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PERMIT DURATION Date: __________ to __________ Time: __________ to __________ POTENTIAL CONFINED SPACE HAZARDS (Consider both Inherent and Task-Specific Hazards)

Oxygen Deficiency Oxygen Enrichment

Flammable Atmosphere Carbon Monoxide

Hydrogen Sulfide Flue Gases

Hot Surfaces Elevated Temperatures

Configuration Hazard Access/Egress Hazard

Fall Potential Sulfur Dioxide

Septic Hazard Drowning Hazard

Burial/Entrapment Hazard Exposed Electrical Energy

Chemical Residue ______________________________ Engulfment ______________________________________ Chemical Vapor/Gas ____________________________ Mechanical ______________________________________ OTHER _________________________________________________________________________________________

PRE-ENTRY REQUIREMENTS

Hazard/Space Isolation Additional Permits Issued:

LOTO Product Removal

Flushing Ventilation

Barricades NONE REQUIRED

Entrant/Attendant Communication Method:

Safety Briefing Potential hazards and control methods Contractor coordination

Tasks being performed Rescue Plan EQUIPMENT REQUIREMENTS Lighting

2-way Radios Portal Barricade Body Harness Lifeline

Access/Egress Equipment Personal Protective Equipment

Tripod / Davit Ladder Scaffold Aerial Other

Hardhat Glasses Hearing Dust Mask APR

Chemical Gloves Coveralls

VENTILATION REQUIREMENTS

None Natural

Mechanical Positive Negative

Pre-Entry Continuous

ATMOSPHERIC TESTING RESCUE PLAN

Continuous Periodic Not to Exceed 12 hrs : Entry Rescue Non-Entry Rescue

Time Oxygen LEL CO H2S SO2 / Other Staged On-site Off-site

Equipment Required:

Notification Method:

ENTRY SUPERVISOR AUTHORIZATION I certify that all required precautions have been taken, all personnel are properly trained, and all equipment needed for safe entry and work in this confined space is available. All entry operations must remain in compliance with the conditions listed on this Permit. Print Name Signature Date

Interval

ENTRY PERMIT SPACE CONFINED

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Attendant #1

Date / Time Attendant #4 Date / Time

Attendant #2 Date / Time Confined Space:

Attendant #3 Date / Time Permit #:

(Person Entering) IN / OUT IN / OUT IN / OUT IN / OUT IN / OUT IN / OUT

/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

FIRST REPORT OF INJURY OR ILLNESS

FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISON OF WORKERS COMPENSATION

For assistance call 1-800-342-1741 or contact your local EAO Office

Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953

PLEASE PRINT OR TYPE EMPLOYEE INFORMATION NAME (First, Middle, Last)

_____________, ___________, ________________

Social Security Number Date of Accident (Month-Day-Year) Time of Accident

AM PM HOME ADDRESS

Street/Apt #:

EMPLOYEE’S DESCRIPTION OF ACCIDENT (Include Cause of Injury)

City: State: Zip:TELEPHONE Area Code Number

OCCUPATION INJURY/ILLNESS THAT OCCURRED PART OF BODY AFFECTED

DATE OF BIRTH SEX

Male Female

EMPLOYER INFORMATION COMPANY NAME: WW Gay Mechanical Contractor, Inc. FEDERAL I.D. NUMBER (FEIN)

59-0977396DATE FIRST REPORTED (Month/Day/Year)

D.B.A.: NATURE OF BUSINESS POLICY/MEMBER NUMBER

Self-Insured Audit # 9910 Street: 524 Stockton Street

City: Jacksonville State: Fl Zip: 32204 TELEPHONE Area Code

904 Number

388-2696DATE EMPLOYED PAID FOR DATE OF INJURY

YES NO

EMPLOYERS LOCATION ADDRESS (If different) LAST DATE EMPLOYEE WORKED WILL YOU CONTINUE TO PAY WAGES INSTEAD OF WORKERS’ COMP? YES

LAST DAY WAGES WILL BE PAID INSTEAD OF WORKERS’ COMP

Street: City: State: Zip: RETURN TO WORK YES NO

IF YES GIVE DATE

LOCATION # (If applicable) PLACE OF ACCIDENT (Street, City, State, Zip) DATE OF DEATH (If applicable) RATE OF PAY HR WK

$ PER DAY MO

Number of hours per day

Number of hours per week

Number of days per week

Street:

City: State: ZIP: AGREE WITH DESCRIPTION OF ACCIDENT?

YES NO COUNTY OF ACCIDENT

Any person who, knowingly and with intent to injure, defraud, or deceive any employer, insurance company, or self – insured program, files a statement of claim containing any false or misleading informationcommits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. I have reviewed, understand and acknowledge the above statement.

EMPLOYEE SIGNATURE (If available to sign) DATE

EMPLOYER SIGNATURE DATE

NAME, ADDRESS, AND TELEPHONE OF PHYSICIAN OR HOSPITAL

Phone:

AUTHORIZED BY EMPLOYER YES NO CLAIMS-HANDLING ENTITY INFORMATION

1(a) Denied Case – DWC-12, Notice of Denial Attached 2. Medical Only which became Lost Time Case (Complete all required information in #3)

1(b) Indemnity Only Denied Case – DWC-12, Notice of Denial Attached Employee’s 8th Day of Disability

Entity’s Knowledge of 8th Day of Disability

Full Salary in lieu of comp? YES Full Salery End Date 3. Lost Time Case – 1st day of disability

Date First Payment Made AWW Comp Rate

T.T. T.T. – 80% T.P. I.B. P.T. DEATH SETTLEMENT ONLY

Penalty Amount Paid in 1st Payment $ Intrest Amount Paid in 1st Payment $

REMARKS INSURER NAME W.W. Gay Mechanical Contactor, Inc. CLAIMS-HANDELING ENTITY Commercial Risk Management, Inc. P.O. Box 18366 Tampa, Florida 33679-8366

813-289-3900

INSURER CODE # EMPLOYEE’S CLASS CODE EMPLOYER’S NACIS CODE

SERVICE CO/TPA CODE # 6042

CLAIMS-HANDLING ENTITY FILE #

Form DFS-F2-DWC-1 (08/2004)

RECEIVED BY CLAIMS-HANDLING ENTITY SENT TO DIVISION DATE DIVISION RECEIVED DATE

WW GAY PRE-JOB BREIFING

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DATE: WORK GROUP: Job # : TASK:

JOB NAME: START TIME: STOP TIME:

TASK DESCRIPTION:

SUPERVISOR: FIRE WATCH: SAFETY WATCH: Work Activity Hazards Particulate/Chemical Exposure Specialized Procedures / Equipment

Airborne Particulates N/A N/A Chemical Exposure Acids Supplied Air Respirators / SCBA Cold / Hot Surfaces Anhydrous Ammonia Chemical Protective Clothes Congested Areas Asbestos Asbestos Abatement Confined Spaces Asphalt Confined Space Entry Cranes / Heavy Lifts Benzene Excavations / Shoring Cranes / Vehicle Work Platforms Caustic Crane Suspended Platform Electrical Shock Chlorine Scaffolding Excavation Hazard Condensate / Boiler Feed Work on Energized Equipment Fall Potential Concrete Dust Lockout / Tagout & Isolation of Systems Fire / Explosion Hazard Diesel Electrical Lockout High Noise Gasoline Crane / Lift Study Heat Stress Hydrogen Sulfide (H2S) Hot Tap Hot Tap Lead Paint Housekeeping Housekeeping MEK Line Breaking (Isolate & Depress) Inadequate Anchorage(s) Natural Gas Other – Notify Safety Department Inhalation / Ingestion Hazards Steam Ladders / Scaffolding Inspection Toluene Personnel Protection Devices Lifting Hazards to Back / Body Water Contaminated Anchorages Line Breaking / Equip. Opening Other: Barricades (Tape & Signs) Overhead Hazards Fire Blanket / Extinguisher / Hose Oxygen Deficiency Work Permits Fire Watch / Safety Attendant Pinch Points N/A Ventilation / Fresh Air Poor Access / Egress Hot Work Ladders / Scaffolding Pressurized System / Piping Confined Space Entry Positioning System Poor / Restricted Lighting Excavation Fall Protection System / Device Rigging Hazards Line-Breaking Safety Shields / Netting Sharp Objects / Punctures Lockout / Tagout Safety Shower / Eye Wash Slip / Trip Hazards Personnel Basket Vapor Proof / Explosive-Proof Lighting Welding / Burning Hazards Area Entry Equipment Grounding / GFCI Weather Hazards Safe Work Permit Other: Overhead Power Lines Other: Underground Hazards Other:

Personal Protective Equipment Required for Task Air Monitor Goggles / Burning Respirator, SCBA Boots, Rubber Chemical Resistant Gloves Respirator, Supplied Air Boots, Disposable Covers Hard Hat Safety Glasses Boots, Safety-Toed Hearing Protection Safety Goggles Clothing, Fire Resistant Life Vest Other: List Below Clothing, Disposable (Tyvex) Respirator, ½ Face Face Shield Respirator, Full Face Fall Protection / Safety Harness Respirator, PAPR

Emergency Action Plan Emergency Contact Number (s): Evacuation Route(s) & Assembly Area: Identified with Personnel? Yes No SDS Available: ☐ Yes ☐ No

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JOB SAFETY / HAZARD ANALYSIS (JSA / JHA)

(A) Steps of Task (B) Hazards Associated withStep

(C) Actions taken toEliminate or Reduce Hazards

• •

• •

• •

• •

• •

• •

• •

• •

• •

• •

USE Table below to fill in section’s “B” and “C” (Write in if not on table)

(B) Hazards Associated with Step (C) Actions taken to Eliminate or Reduce Hazards1 Slips, Trips & Falls A Watch foot placement, Ensure path is clear.

2 Welding Hazards B Use proper PPE (Welding Hood, Jacket), Have fire watch in place, Insure there is no flammables or combustibles with 35 feet of work area.

3 Falling from Heights C 100% tie-off when above 4 feet, Maintain 3 points of contract if using ladder.

4 Strains & Sprains D Use proper lifting, Pushing & Pulling Techniques, Stretch prior to starting work activities.

5 Pinch Points E Keep all body parts out of pinch points.

6 Falling objects F Use proper rigging techniques, Never lift a load over people.

7 Excavation Cave-in G Use proper sloping/Benching/shoring system, Means of egress placed every 25’, Follow inspection requirements.

Personnel Below Participated in Discussing Specific Work Responsibilities, Hazards and Required Safety Measures Concerning this Task

Comments:

Was Anyone Hurt: Yes No Did a Nearmiss Occur: Yes No

Foreman’s Signature: Date:

LIFT FORM

Section to be filled out for Critical Lift

Page 1 of 2

Lift Location: Job # Date of Lift: Load Description: Lift Description: Job Foreman: Weather Conditions:

Name of Operator: Up to Date Drug Card Yes No License Number

Diagram of Crane Lift and Load Placement Attached: Yes No Diagram of Rigging and Load Attached: Yes No

LOAD WEIGHT HOIST ROPE Load Condition: New Used Rope Diameter: Weight Empty: Number of Parts: Weight of Contents: Lift Capacity Based on Parts: Weight of Auxiliary Block: Non-Destructive Test Preformed on Hook: Yes No Weight of Main Block: JIB Weight of Lifting Beam: Erected Stowed Weight of Slings: If Jib is to be used: Weight of Shackles: Rated Capacity of Jib from Chart: Weight of Boom Extension: CRANE Erected: Stowed: Anti-two-block Device on Crane: Yes No Load Line Weight: Type of Crane: Weight of Extra Hoist Rope: Make/Model of Crane: Weight of Excess Load Material: Crane Serial Number: Other: Maximum Crane Capacity: Total Weight Crane Inspection Date: Source of Load Weight (Drawings, Calculations, Etc.)

Size of Mats Used: Mats Not Required Outriggers Extended : Fully Partly Retracted N/A Lifting Position: Side Rear Front All Radius at Pickup: Set Down:

RIGGING & RIGGER/SIGNALER Crane Capacity at Radius: Over Front: Qualified Rigger and Signaler: Yes No Over Rear: Over Side: Rigging Size: Type: Boom Angle at: Pick-up: Sit-down: Sling Assembly Rated Capacity: Rated Capacity of Crane for this Lift at

the Maximum Radius and Boom Angle is:

Number of Slings: Sling angle factor: Hitch Type: Vertical Choked Basket Rigging Deduct: Maximum Load Being Lifted is: Shackle Size: Type: Percent of Cranes Rated Capacity: Shackle Rated Capacity: Is the Crane Rated for the Load: Yes No Number of Shackles: Notes:

Is the Rigging Rated for the Load: Yes No All Lifting Equipment Inspected: Yes No Rigging Secured to Load by: CRANE CONFIGURATION

Are Lifting Devices on Load in Good Shape: Yes No

IF “NO” What Provisions Will Be Made:

Main Crane Tailing Crane What Counterweight Configuration Required: Is the Computer Set Per Crane Configuration? Yes No Is the Computer in the Proper Mode? Yes No Is the crane level? Yes No

CRANE PLACEMENT What is the Ground Conditions? Have ground locates been conducted? Yes No N/A If “No” what provisions will be made? Is Lifting/Swing Area Unoccupied and Barricaded: Yes No Notes: High Voltage or Electrical Hazard? Yes No If the crane can come in to contact with a power line with the boom length being used for the lift a Crane Operation

Around Power Lines form must be completed or crane supplier contacted.

Obstacles/Obstructions to Lift or Swing? Yes No Notes:

LIFT FORM

Section to be filled out for Critical Lift

Page 2 of 2

Travel Required for Lift? Yes No Notes: Swing Restrictions? Yes (Describe) No Describe Restrictions: Swing Direction? Left Right Signal Communication Method: Hand Voice Radio Other -

PRE-LIFT CHECKLIST (COMPLETED PRIOR TO LIFT) Crane Inspected Crane Counter Weight Wind Signatures Rigging Inspected Load Test Temperature Crane Set-up Operator Qualified Safety Spotter Swing Room Rigger Qualified Traffic Hoist Heights Signal System Pre-Lift Meeting Head Room Tag Lines Site Control

Lift Supervisor Signature DATE Operator Signature DATE

Customer Designee Signature DATE Signaler Signature DATE

Safety Designee Signature DATE Rigger Signature DATE

Pre-Lift Meeting Attendants

Critical Lift Definitions • Lifting personnel. • Lifting above 75% of the capacity of the crane. • Lifting a piece of equipment that is difficult to replace. • Damage that would cause serious economic consequence.

SERVICE DEPARTMENT PRE-JOB BRIEFING

JOB NAME: START TIME: STOP TIME: JOB # FIRE WATCH NEEDED: YES NO OTHER CONTRACTORS: TASK DESCRIPTION: SUPERVISOR: DATE: ALL EMPLOYEES HAVE RECIVED NEW HIRE SAFETY TRAINING: YES NO

MINIMUM PPE REQUIRED FOR THIS TASK BOOTS, STEEL-TOED HARD HAT SAFETY VEST/HI-VIS SHIRT SAFETY GLASSES

ADDITIONAL PPE REQUIRED POTENTIAL JOB HAZARDS AIR MONITOR WELDING PPE OIL REFRIGERANT ELECTRICAL FR CLOTHING GLOVES WELDING/CUTTING/BRAZING GASSES TYVEK - COVERALLS HEARING PROTECTION BOOM TRUCK/CRANE FACE SHIELD HOUSEKEEPING ROOF WORK FALL PROTECTION SAFETY GOGGLES MANLIFT/SCISSOR LIFT FALL PREVENTION RESPIRATOR CAUTION/DANGER TAPE OTHER PPE: LADDER

SEWAGE COMPETENT PERSON NEEDED YES NO For:

STEPS OF TASK HAZARDS ASSOCIATED WITH TASK ACTIONS TO ELIMINATE OR REDUCE HAZARDS

PERSONNEL BELOW PARTICIPATED IN DISCUSSION SPECIFIC TO WORK RESPONSIBILITIES, HAZARDS AND REQUIRED SAFETY MEASURES CONSRNING THIS TASK. Print your name and initial beside your name that you understand the task. At the end of the day, initial that you had no injuries unless reported to your supervisor.

NAME INITIALS NO INJURY NAME INITIALS NO

INJURY

Was anyone injured or hurt? YES NO Any Near Misses? YES NO Comments:

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Workers’ Compensation Medical Treatment Facilities

Florida/Georgia

Amelia Urgent Care Amelia Urgent Care Amelia Urgent Care

904-321-0088 904-696-0055 912-729-2821

96279 Brady Point Road

Fernandina Beach

510 Airport Center Drive, Suites 108-110

Jacksonville, FL 32218

1481 Highway 40 East

Kingsland, GA 31548

SR 200 (A1A) at Brady Point 1 mile east of

Lowe’s

Between Jimmy Johns and Navy Federal

Credit Union Across form Lowe’s

Amelia Urgent Care St. Vincent’s First Care Concentra Care

912-496-0041 904-786-0440 904-482-1400

3435 Second Street

Folkston, GA 31537

7963 Normandy Blvd

Jacksonville, FL 32221

1584 Normandy Village Pkwy, Suite 32

Jacksonville, FL 32221

On U.S. 1, South of Harvey’s

Lakeshore Medical Center Medex Care Helix Urgent Care

904-384-5385 386-326-0575 772-463-1123

4570 San Jan Avenue, Suite 2

Jacksonville, FL 32210

6500 Crill Avenue

Palatka, FL 32177

6522 Kanner Hwy

Stuart, FL 34997

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W. W. Gay Mechanical Contractor

Workers’ Compensation Medical Treatment Facilities

Florida/Georgia

Baptist Medical Hospital Baptist Beaches Hospital Healing Arts Urgent Care

904-202-2000 904-247-2980 904-823-3401

9627800 Prudential Drive

Jacksonville, FL 32207

1350 13th Avenue South

Jacksonville Beach, FL 32250

120 Health Park Blvd,

St. Augustine, FL 32086

Medi-Test Occupational Lakeside Medical Center Prime Care

863-533-7484 813-980-3151 386-274-2212

1350 E main Street, Suite C1

Bartow, FL 33830

10320 North 56th Street, Suite 110

Temple Terrace, FL 33617

1890 LPGA Blvd, Suite 130

Daytona Beach, FL 32174

First Care Occupational Quest Diagnostics Glynn Intermediate Care Center

352-373-2340 3866-697-8378 912-466-5800

4343 W Newberry Road

Gainesville, FL 32607

324 E Par Street, Suite 100

Orlando, FL 32804

3400 Parkwood Drive

Brunswick, GA 31520

WW Gay Accident Investigation Report Page 1 of 2

ACCIDENT INVESTIGATION REPORT

Facility: Date: Location: Department: Address: Employee/Subcontractor: Foreman: Customer Point of Contact:

Last Name of Injured (or ill) Person

First Name

Job Number

Years in Trade

Time on Present Job

Trade

Hours Worked in Previous 24 Hour Period

Activities immediately preceding accident

Weather Conditions

Employee condition immediately prior to accident Alert Fatigued

Accident Location (Bldg or Area) Be specific:

Date of Accident

Time of Accident

Accident Category Injury or Illness

Equipment Malfunction

Motor Vehicle

Property Damage Fire Nearmiss Other (Specify)

Nature of Injury or Illness

Name(s) and titles of person (s) who investigated accident:

Print Name & Title: Phone:

Print Name & Title: Phone:

Print Name & Title: Phone:

Print Name & Title: Phone:

Name(s) of Witness(s) (include phone number)

Description of Accident or Employee's Account of Occupational Disease (use separate sheet if necessary)

Was a Written JSA available?

YES NO

Was it being followed?

YES NO

Was the hazard identified on the JSA?

YES NO NA

Was JSA reviewed by the work crew and foreman?

YES NO

Was Proper PPE available? YES NO

Was it being used? YES NO

Was it adequate? YES NO

Did it Fail?

YES NO

Was the employee trained in its use?

YES NO

WW Gay Accident Investigation Report Page 2 of 2

Basic Cause (and Contributory Factors) EXPLAIN FULLY UNSAFE CONDITIONS

Corrective Measures Taken and/or Recommended

Corrective Action Referred To: Date To Be Completed By:

Additional Comments or Observations. Where applicable give details of makes & models of machines, equipment, tools, structures, etc., involved in this accident. (Use separate sheet if necessary)

cc: WW Gay Safety Department Department Manager Project Superintendent