REP03942

• Permit No: M1977424
• IBM Index Class Name: Report
• Doc Date: 8/14/1995
• From: DAMES & MOORE
• To: DMG
• Media Type: D
• Archive: No

`-r,~_ -- DAMES S MOOT'.E•
1 PROJECT HEALTH AND SAFETY REGIUIREMENTS
SUBCONTRACTOR COMPLIANCE VERIFICATION
' This document is tlesigned to permit the Dames € Moore Project Manager to evaluate a subcontractor's compliance wjtt
the health and safety aspects of the subcontractor agreement. The Project Manager completes the top portion of this
document, and provides a copy of the document to each subcontractor who will be participating in project field activities.
The subcontractor completes the second portion of the document, signs it, and returns it to the Dames & Moore Project
Manager prior to the start of work.
~ Project Name /Location
' Job Number
' Protect Manager /Location
Subcontractor
' Tasks
Project Dates through

LJ

SUBCONTRACTOR
Subcontractor certifies that all of subcontractor's personnel assigned to this project have
received 40 hour health and safety training that meets Lhe requirements of 29 CFR 1910.120 (e}.
Initials
Subcontractor certifies that the subcontractor's field supervisor has completed 8 hours of
supervisor training that meets the requirements of 29 CFR 1910.12D (e)(4).
Feld Superviso"s Name
Print Name
Inrals
Subcontractor certifies that all of subcontractor's personnel assicned to this project are participating
in a medical surveillance program that mees the requirements of 29 CFR 1910.120 (f).
Inbals
Subcontractor understands that subcontractor is responsible for providing asite-specific health
and safety plan for this project that meets the requirements of 29 CFR 1910.120 (b).
Subcontractor initials here if subcontractor will provide its own health and safety plan.
Subcontractor initials here if requesting Dames ~ Moore's assistance in preparing jts
health and safety plan.
Subcontractors Representative
Print Name
Subcontractors Representative
Sicnature
Ini[iats
Inirals
Initials
CcPy Tc: Projett File; Contact I Ac~unony File
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