Form BPA F 5480.28e BPA F 5480.28e EXCAVATION / TRENCHING PERMIT

BPA F 5480.28e
(xx-2023)

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U.S. DEPARTMENT OF ENERGY - BONNEVILLE POWER ADMINISTRATION (BPA)

OMB Control Number:1910-XXXX

Expiration Date: xx/xx/xxxxx
EXCAVATION / TRENCHING PERMIT
This Permit is required for excavations or trenching for all conditions listed below:

Any trench greater than 5 feet in depth -- sloping or shoring is required.
Permit to be completed by the employee in charge of the job and the
Competent person before work begins and must be posted at the job site.
Copies of this Permit will be maintained by the crew foreman for 10 year
after job completion.

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Prior to entry into a trench 4 feet or greater in depth.
Work requiring the worker to position their entire body below the top of
the excavation.
When outside utility services are involved -- a locate call is required.

PERMIT START DATE:
LOCATION:
NAME OF COMPETENT PERSON:

EXPIRATION DATE:
NATURE OF WORK:
NAME OF EMPLOYEE IN CHARGE:

Depth and width of Trench (approximately)

Width
Depth
Stable Rock
Type: A
B
C
C60
Visual
Penetrometer
Thumb
Shearvane
Reading:
Weather Conditions:
Sloping
Benching
Other
Shielding
Shoring
Trench Box
Is tabulated data on site:
[depth x soil type = dist.]
calculated ft.=
Yes
Approximate Distance:
Yes Accomplished How?
Yes Describe conditions and abatement methods:

Soil Type Determined
Testing Method / Reading / Weather:
Protective System Plan:
Vendor used:
If sloping and/or benching are used; calculate the distance required
A=3/4:1 (53*) B=1:1 (45*) C=1½ :1 (34*)
Spoils stockpiled greater than 2 feet from edge of excavation or 1:1
[depth:distance]
Excavator/equipment/vehicle will maintain a safe distance from trench
Hazardous atmospheres or conditions are identified and abated
Egress is provided for all excavations greater than 4 feet in depth and
at a distance requiring no greater than 25 feet of travel
Fall protection/barriers/walkways provided where needed
Utility Locates
Rescue Plan (describe)
COMPETENT PERSON Signature

Ladder
Stairway
Ramp
Other
Note: ladders cannot be used for slopes less than 60*
Yes
Locate Call Made:
Yes
No
List Utilities involved:

EMPLOYEE IN CHARGE:

Name of person(s) performing the work:
1.
4.
7.

2.
5.
8.

10.
13.

11.
14.

Yes

By signing you verify that the required precautions will be taken

Additional names written on attach document?
3.
6.
9.

Yes

12.
15.
File Code; PE 53-17

Retention; 10yrs

No

BPA F 5480.28e
(xx-2022)

U.S. DEPARTMENT OF ENERGY - BONNEVILLE POWER ADMINISTRATION (BPA)

EXCAVATION / TRENCHING PERMIT

OMB Control Number:1910-XXXX
Expiration Date: xx/xx/xxxxx

Paperwork Reduction Act Burden Disclosure Statement
This data is being collected to ensure the safety of BPA’s contract workers. The data you supply will be used by BPA to ensure safe work planning by
contract workers for trenching and excavation work. Public reporting burden for this collection of information is estimated to average .3 hours per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining that data needed, and completing
and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
Office of the Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22, Paperwork Reduction Project (OMB control
number 1910-XXXX), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and
Budget (OMB), OIRA, Paperwork Reduction Project (OMB control number 1910-XXXX), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply
with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of Management and Budget
(OMB) before undertaking a collection of information directed to 10 or more persons of the general public, including persons involved in or supporting
the operations of Government-owned, contractor-operated facilities.
Submission of this data is mandatory.