Job Safety Date: July 20, 2010 Page 1 of 3

Analysis Master Document No.

Complete daily (before beginning work or at shift change) and review when work is complete.
(1) JOB INFORMATION
Job Name: Job Number: Longitude: Latitude: Supervisor:
TOWNLY JW GIBSON

(2) PROJECT PERSONNEL (List Date of all Certifications Obtained below)

Name: Company: CPR/ 1st Aid OSHA 10/30 Fall Protection Tower Rescue Certifi\IED

(3) EMERGENCY PROCEDURES (List telephone numbers and attach directions to the site.)
XYes No Cell phone coverage? XX Yes No 911 system functional w/ cell phone?
Yes No Hard-Line coverage? Yes No Calling Tree accessible?
Yes No Is rescue crew trained in tower rescue procedures and immediately available?
Ambulance: Fire: See attached Police: See attached Local Hospital: See attached
See attached
Telephone Co: Utility Co: Evacuation Point Construction Manager:

(4) JOB/TASKS FOR SCOPE (Check work being performed)

Line/Antennas Tower Erection X Civil/Concrete X Electrical Burn, Grind, Weld/Exothermic Weld
X Testing Decommissioning Night-Hot Cut Over x Other (describe) Site inspection
Jobs/Tasks Potential Hazards Preventive Measures
(List jobs in sequential steps) (List hazards for each step) (List control for each hazard)

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 Job Safety Date: July 20, 2010 Page 2 of 3

Analysis Master Document No.

Inspect site for proper civil work. Trips, Pay attention while walking
View tower top with binoculars Fall back wards Lean on fence while looking up
Inspect coax and ground connections Fall from 4’ ladder Pay attention while on ladder
L&A Work Fall from Tower Pay attention while on Tower
Civil Work Electrical Shock All safety gear worn properly
Electrical Work Adhere to all safety procedures

(5) JOBSITE EXPOSURES (Items checked below relate to existing conditions or site operations)
Physical Hazards Health Hazards
Confined Space Permit Req’d Overhead Utilities Biological Hazards High Noise (> 85 dBA)
X Electrical X Slips, Trips, or Chemical Exposure Lifting Hazards
Elevation/Site Terrain Falls EME/RF Silica Exposure
X Fall from Elevation Underground Environmental Hazards Other:
Fire Hazard Utilities HazMat Disturbance
Heavy Equipment X Vehicle Traffic Heat Stress/Cold Stress
Other:
(6) HAZARD CONTROL MEASURES
Personal Protection & Inspections
Safety Program/Training Fire Prevention/Inspection
Monitoring Equipment Complete prior to use
X Fall Protection Crane 4-in-1 Sign Fire Extinguisher Charged
Gloves Gin Poles, hoist, or Excavation Log Fire Extinguisher Certified
X Hard Hat capstan Lockout/Tagout Protective Screen/Blankets
Hearing Protection Housekeeping Permit System (Hazardous Work, Transverse side of welding area
X RF Monitors Ground Fault Confined Space, Excavation, etc.) Inspected (heat transfer & conduction)
RF Suits Protection Pre-Approved Plans (Critical Lifts,
Tag Lines Controlled Descent, Suspended Fire Watch Begins __________
X Safety Glasses Fire Watch Ends __________
X Safety Shoes Rigging Personnel Platforms, or Welding)
(30 minute minimum)
Tools/Equipment Tailgate Meeting
Other:
NOTE: Notify the Market ES&H Manager before entering a trench/excavation that is greater than 5’ deep or before entering a Confined
Space (above or below ground).
(7) COMPLETE FOR CIVIL WORK
A. Describe type and depth of excavations:
B. Utility Locate work order number: Effective Date: Expiration
Date:
C. Have all owner identified underground obstructions been located & marked? Yes No
D. Cave-in control measures to be used if excavation will be greater than 5 feet and personnel are entering the trench:
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 Job Safety Date: July 20, 2010 Page 3 of 3

Analysis Master Document No.

Sloping Benching Shoring Trenching Shield/Box Ladder in Trench at 4 Feet

E. Describe elevation/site terrain/ environmental concerns or hazards:
F. Describe hazards with site/vehicle access (e.g. boom and cranes/electrical lines) and storage of materials:
G. Describe the type of electrical concerns or hazards:

(8) COMPLETE FOR ELEVATED WORK (Fall protection & elevated work platforms)
Type of elevated work location: Type of Antenna Boom:
X Descenders X Retractable Life
Anchorage Straps Rope Grab
Fall protection to be used: X Full Body line
Cable Grab Double leg or 2 lanyards
Harness X Ropes
A. Describe the fall protection system to be used when accessing antenna booms or performing tower erection:
B. Each employee inspected fall protection equipment? Yes No
C. Are employees ComTrain certified? Yes No
D. Hoisting Equipment to be Aerial Suspended Personnel Platform (SPP) (manbasket)
used: Lift   Yes No SPP Permit Completed? Yes No Critical Lift Plan completed & on site?
Gin Pole
(9) REVIEWS AND SIGNATURES
Lower-tier Subcontractor Employer
Name Signature/Date Name Signature/Date

Name Signature/Date Name Signature/Date

Name Signature/Date Name Signature/Date
Name Signature/Date Name Signature/Date
Name Signature/Date Name Signature/Date
Name Signature/Date Name Signature/Date
Name Signature/Date Name Signature/Date
Name Signature/Date Name Signature/Date

REV FORM REVISED