subcontractorconstructionsafetysite-specificsafetyplanform（17页）.docVIP

Project Title SECTION 1 - PROJECT DESCRIPTION EMERGENCY CONTACTS Subcontract / Purchase Order Number Project Start / End Dates Start: Complete: Project Location General Scope of Work, Project Description FOR ALL EMERGENCIES CALL: Emergency Contact number: 7911 - or - (510-486-7911) or 911 from a cell phone. For all incidents, injuries, property damage, near-misses, work-induced illness or chemical over-exposures, the following personnel MUST be immediately contacted upon scene stabilization, but in all cases within one hour: Project Personnel Name Phone Number(s) Email Project Manager Construction Manager Project EHS Point of Contact OTHER CONTACT INFORMATION Subcontractor Project Manager Subcontractor Site Superintendent Subcontractor Health Safety Representative ** Subcontractors - Company Name Name of Designated Safety Representative ** Phone Number TBD TBD ** Attach a description of qualifications, or resume, for each Safety Representative per Section 9.0 plan attachments. SSSP REVIEWS Reviewed Approved by: (Subcontracted Company Officer) Subcontractor SSSP Reviewed by: (LBNL EHS ) Subcontractor SSSP Reviewed Accepted by: (LBNL Project/Construction Manager) Signatures and dates SECTION 2 - SUBCONTRACTOR POLICY STATEMENT  SECTION 3 - ACKNOWLEDGMENT of 10 CFR 851 As a subcontractor to LBNL, while your workers are physically located at LBNL, you must meet the requirements of Title 10, Code of Federal Regulations, “Energy”, Part 851, “Worker Safety and Health Program” (10 CFR 851). As such, you must be aware of, and comply with, the requirements of this regulation. (Link to 10 CFR 851) Acknowledgment signature __________________________ I__________________________________, certify that that I have read the requirements of 10 CFR 851 and attest that my firm and its sub-tier contractors will comply with the requirements of 10 CFR 851. Yes No MEDICAL SURVEILLANCE AN