CONTACT DETAILS
Name of Employee that will be in Responsible Charge on-site during the access of the Sanitary Sewer.
Name of Applicant Firm or Government Agency: *
Purpose of the Request (Surveying, CCTV, COVID-19 Sampling, etc.): *
PERMIT DETAILS
Specific Performance Time Period. (Access by the Applicant either before or after the stated time period shall constitute a violation of this Regional Wastewater Reclamation Department Directive).
Permit Activation Date: * Time: *
Permit Termination Date: *
Permit is for:
*Location of Structure/Manhole:Right of Way Access: The Permitee is responsible for the jurisdiction’s Right of Way use permit, all traffic control and safety compliance measures necessary to protect the public and employees, and any other permits required to perform the work.
In the event of dropped equipment or an incident in the field, contact RWRD at (520) 724-6500. For Emergencies call 911.
Certifications
Applicant certifies, by signature below, that when this permit is marked above for “Physical Access and Entry” the employees performing the work (including the physical entry) shall:
- Be properly equipped with industry-standard confined-space entry safety equipment and atmospheric monitoring equipment suitable for a hazardous sanitary sewer environment.
- Have been trained in and will employ OSHA confined-space entry safety procedures (29 CFR §1910.146 or successor provisions).
Permit Conditions
- Upon request, applicant will provide RWRD with a copy of the written confined space entry procedures that will govern the confined space entry and/or the training records of the individuals that will physically perform the confined space entry.
- The applicant will indemnify, defend, and hold harmless Pima County, its officers, departments, employees, and agents from and against any and all suits, actions, legal or administrative proceedings, claims, demands, or damages of any kind or nature which result from any act or omission of applicant, its agents, employees, or anyone acting under its direction, control, or on its behalf unless due solely to county negligence.
- The Sanitary Sewer Access Permit shall neither constitute nor replace the Confined Space Entry Permit that the applicant must issue, in accordance with the applicant’s written confined space entry procedures as required for OSHA compliance, at the site of and at the time of the physical confined space entry.
SIGNATURE
By electronic submission of this permit application, I hereby certify that all of the information I have provided is true and correct, that I am duly authorized to submit this application on behalf of the permit applicant, and that the permit applicant will fully comply with all conditions of the permit.
*By(Name): * Date:
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