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Date

Yes No IA CheckYes No IACheck

Welfare facility (water-salt-shaded area)

Communicationmeans

Hearing Protection

Others specify

Dust Masks

Safety Glasses

Goggles

GlovesStandard PPE(Saftety helmet, boots& coveralls)

C. Other Precautions

B. Personal ProtectionIA

CheckNo

Book Out/Book In

Barrier off areas restrcited for excavation

Establish & mark out position of underground services

Information Safety & Loss Prevention ( in case of blocking roads)

Banksman to be provided

Excavation by mechincal means after pilot trenches (min. 3m from serv.)

Shoring/Sloping (excavation more than 1.2m in depth)

Expose underground services byhand digging

Proper access and egress

Cable detector to be used

Confined Space Entry cert. (excavation more than1.2m deep)

Warning signs to be placed

Markers/ Lighting

Yes

Sign

Please tickappropriate box

28 - Jun - 2011

EXCAVATION CERTIFICATE

HrsTimeDateName

I, Issuing Authority have visually inspected the precautions and conditions stated by AA. I approve the work to be started.

HrsTimeDateName

Area Authority (A A)

I, the Area Authority , have inspected the work area and found it clean-clear-safe and area came back to normal.

I, the Job Performer, declare that the work is completed and the work site has been left clean-clear and safe and the excavationhas been backfilled and road blockage cleared.

SECTION 6 VALIDITY OF CERTIFICATE (AA/IA)

SECTION 7 CERTIFICATE / CANCELLATION CLOSE-OUT (JOB PERFORMER / AREA AUTHORITY- JP/AA)

I have examined the drawings of the proposed excavation, and of adjacent underground services. I confirm that the excavation mayproceed subject to comments noted below.

SECTION 5 AUTHORISATION (AA / IA)

SECTION 3 DEPARTMENT APPROVAL (Departments to be consulted to be specified by the Area Authority)

SECTION 2 DETAILS OF EXISTING UNDERGROUND SERVICES NEAR EXCAVATION (AREA AUTHORITY-AA)

SECTION 1 EXCAVATION REQUEST (JOB ORIGINATOR-JO) / (JOB PERFORMER - JP)

No. Of DaysDate:hrsTo:hrsValidity Time: From:

Tools/Equipment to be used

m (W / D) ratiom Depth(D)Width(W)Excavation Dimension:

Method StatementJob Hazards Analysis to be attached

PTW required

Restricted area

Yes NO

SignatureSec./Dept.Originated By Name

ChannelRadioNoPhone/PagerJob Performer Contact Details:

Name:

As-built drawing marking limitof excavation to be attached

ContractorSection:ADCO:

PTW No.

Job Performer Name:

Description of Work

Location of Work:

Adco Area:

Barriers at least 1m from excavation

SECTION 4 PRECAUTIONS (AREA AUTHORITY- AA) (ISSUING AUTHORITY - IA)

MechanicalManual excavationPilotAA Signature

Electrical

Flow-Line/Pipline

Cathodic Protection

Department Remarks/Conditions/Observations Supervisor Signature Post Date

Telecom.

Instruments

Job Performer (JP)

I, AA authorise the excavation work specified above to be carriedout subject to the nominated safety precautions and conditionsbeing maintained during validity period specified in Section 1 of thiscertificate.

AA

IA

Time

Day Sat Sun Mon Tue Wed Thu Fri

Date

ABU DHABI COMPANY FOR ONSHORE OIL OPERATIONS (ADCO)

Certificate No.a

A. Worksite Precautions

24810