TEMPORARY ACQUISITION OF LAND

(Reporting by Contractor to CSC) Construction Stage: : Date :

Supervision Consultant:
Sl. No Item Target Date for Establish ment Date of Establish ment Location (CH)

Civil Contractor:
Present Landuse Size (mxm) No. of Trees (>30 cm girth) Dist from Nearest Settlement

Contract Package:
Distance form Nearest Water Source Remarks by CSC, if any

1 a b c d 2 a b 3 a

Borrow Areas (BA) BA 1 BA 2 BA 3 BA 4 Site for Quarry (QS) QS 1 QS 2 Workers Camps (WC) WC 1

Sl. No

Item

Target Date for Establish ment

Date of Establish ment

Location (CH)

Present Landuse

Size (mxm)

No. of Trees (>30 cm girth)

Dist from Nearest Settlement

Distance form Nearest Water Source

Remarks by CSC, if any

b 4 a b 5 a b 6 a b

WC 2 Site for Stone Crusher Unit (SCU) SCU 1 SCU 2 Site for Hot Mix Plant (HMP) HMP 1 HMP 2 Site for Stock Yard (SY) SY 1 SY 2 Site Layout plan of all locations

Documents to be attached:

Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

BORROW AREAS IDENTIFICATION

(Reporting by Contractor to CSC) Construction Stage Report: (Format to be submitted before target date for establishing Borrow Area) Supervision Consultant: Civil Contractor: Borrow Area No: Location of Borrow Area (Ch. & Offset): Item Date of Borrow Area becoming operational Current Landuse No of settlements within 800m of Borrow Area Details of nearby water bodies Details of Water sources for dust suppression Quantity of water required for dust suppression i.e. sprinkling at borrow area and on non-metal haul road Availability of water required for dust suppression Details of ecologically sensitive area i.e. RF, PF, Sanctuary etc. within 500m Details of school, hospital and any archaeological sites within 500m Distance from nearby road embankment Distance from nearest fence line / boundary No of Trees with girth more than 0.3 m Quantity of top soil to be removed Unit dd/mm/yy Nos. Type/Dist. Type/Capacity/ Present Use/ Ownership Cum. Cum. Type / Name/ Dist. Type / Name/ Dist. m. m. Nos. Sq.m & depth in cm Details Ok Not Ok Date: Contract Package: Engineer Remarks

Item Details of storage of top soil Width of Haul road Total Length of Haul Road Length of Non-metal Haul Road No of settlements within 200m of Nonmetal Haul Road Size of Borrow Area Area of Borrow Area Maximum depth of pit Quantity Available Quantity of top soil removed Details of storage / stacking of topsoil

Unit

Details Ok Not Ok

Engineer Remarks

m km. km. Nos. Sq.m mxm m Cum. Cum.

Documents to be attached: 1) Site plan and layout plan of borrow area; 2) Proposed borrow area operation and redevelopment plan 3) Written consent from competent authority for use of water for dust suppression Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: : CSCs RE

QUARRY SOURCE IDENTIFICATION

(Reporting by Contractor to CSC) Construction Stage Report: (Format to be submitted before target date for establishing Quarry Site) Supervision Consultant: Quarry No.: Item Location License no License Valid till Present land use Predominant wind direction Size and area of Quarry Quantity Available m xm & Sq.m Cum Date Civil Contractor: Location of Quarry (Ch. & Offset): Details Ok Date: Contract Package: Not Ok Engineer Remarks

Unit Ch. & offset

Quantity proposed to be Cum collected No of Trees with girth more Nos. than 0.3m No of Settlements within 500m Nos of Quarry Width of Haul road m Total Length of Haul Road Length of Non-metal Haul km km

Item

Unit

Details Ok Not Ok

Engineer Remarks

Road No of Settlements within 200m Nos. & Name of Non-metal Haul Road Details of nearby water bodies Type/Dist. Quantity of water required for dust suppression i.e. sprinkling at borrow area and on nonmetal haul road Details of Water sources for dust suppression Availability of water required for dust suppression Whether Crusher Plant located on Site Cum. Type/Capacity/ Present Use/ Ownership Cum. Yes/No

Documents to be attached: 1) Site plan and layout plan of quarry site 2) Proposed quarry site operation and redevelopment plan 3) Written consent from competent authority for use of water for dust suppression Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

SITE IDENTIFICATION AND SETTING UP OF WORKERS CAMP

(Reporting by Contractor to CSC) Construction Stage Report: (Format to be submitted before target date of establishing camps) Supervision Consultant: Camp No. : Sl. Item No 1 Detail of camp site a Details of location Ch. b c d e f g Size and area of Camp Date of camp becoming operational Present land use Details of nearby settlement Details of nearby water bodies Details of nearest forest or any other ecologically sensitive area No other trees with girth>0.3m Unit Civil Contractor: Location of Camp (ch & offset): Details Ok Not Ok Engineer Remarks Date: Contract Package:

mxm & Sq.m dd/mm/yy

Name/type /dist. Type / dist. Type/dist

Nos.

Sl. Item No 2 Details of top soil stacking a Quantity of top soil removed b 3 a b c d e f 4 a b c d e f Detail of storage of topsoil Details of workforce Total No of Labourers Total no of Male Workers No of male Workers below 14 years of age Total no of Female workers No of Female workers below 14 years of age No of children (below 14 years of age) Details of dwelling units No of dwellings Minimum size of dwelling No of openings per dwelling Minimum size of opening Walls Roofing

Unit Sq.m & depth in cm Describe stacking arrangement Nos. Nos. Nos. Nos. Nos. Nos. Nos. Mxm Nos. Nos. Specifications Specifications

Details Ok Not Ok

Engineer Remarks

Sl. No g Flooring 5 a b c d e f g h i

Item

Unit Specifications

Details Ok Not Ok

Engineer Remarks

Details of Service Facilities Drinking water tank Size and capacity of Drinking water tank Capacity of Water Tank for WCs/ Bathrooms and general purpose Total no of WC No of WC for female workers Details of WC Total No of Bathrooms for female workers Size of septic tank for WCs/ Baths Two bins household solid waste collection system (one for kitchen waste and another for other waste) Details of household solid waste disposal system Details of fuel for cooking i.e. kerosene with stove, LPG etc. Electricity arrangement Specifications mxmxm & Cum. Cum. Nos. Nos. Specification Nos. Mxmxm Yes/ No

j k l

Sl. No m n 6 a b c d

Item Drainage around the camp site leading to nearby natural drain Fencing around camp Details of other facilities Availability of security guard 24 hrs a day Availability of First Aid Facility Appointing Local Medical Officer for Periodic Health Check-up Details of nearest town/settlement with medical facilities

Unit Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Name / dist.

Details Ok Not Ok

Engineer Remarks

Documents to be attached: 1) Site plan and layout plan of Construction Workers Camp; 2) Working drawings of dwelling units with allied facilities 3) Written consent from competent authority for supply of water and electricity to the camp, if applicable Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

SITE IDENTIFICATION AND SETTING UP OF STONE CRUSHERS, HOT MIX PLANT AND WMM PLANT
(Reporting by Contractor to CSC) Construction Stage Report: (Format to be submitted before target date for establishing Plants) Supervision Consultant: Plant No.: Item Location Predominant wind direction Installed capacity of the plants Size and area of the proposed plant site Present land use Presence of dwelling units within 250m from the stone crusher plant boundary Presence of dwelling units within 500m from the hot mix plant boundary Presence of boundary of State highways and National Highways within 250m from the plant boundary Distance from sensitive areas such as religious places, schools/educational institutions and rivers / lakes Details of water bodies within 500m No of Trees with girth more than 0.3 m within the plant site Yes/No Yes/No Yes/No Unit Ch. & offset tph m xm & Sq.m Civil Contractor: Location of Plant (Ch. & offset): Details Ok Not Ok Date: Contract Package: Engineer Remarks

Type/dist Type/Dist. Nos.

Item Width of Haul road Total Length of Haul Road Length of non-metal Haul Road Details of dust and emission control measures in stone crushing plant i.e. covered conveyor system, water sprinkling at jay crusher, cyclone separator and wind brake wall Sedimentation tank for effluent from water sprinkler Emission control devices for hot mix plant and WMM plant Quantity of water required for dust and emission control in the plants Details of water sources Availability of water required for dust and emission control in the plants Greenbelt along the periphery of plant site

Unit m km km Yes/No

Details Ok Not Ok

Engineer Remarks

Yes/No Yes/No Cum. Type / Capacity/ Present Use/ Ownership Cum. Sq.m

Documents to be attached: 1) Site plan showing wind direction and other environmental features; 2) Detailed layout plan showing environmental mitigation measures 3) Written consent from competent authority for use of water for dust suppression and emission control Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

IDENTIFICATION AND SETTING UP OF MATERIAL STORAGE AND WASTE DISPOSAL SITES

(Reporting by Contractor to CSC) Construction Stage Report: Supervision Consultant: Sl. No. 1 a b c Item Storage Site for Hazardous Fuel, HSD & Chemicals (Pains, Varnish, Glue, adhesive etc.) Volume of storage tanks lit. The capacity of storage area (shall be 110% of 1.a) Is impervious base (concrete) with embankment and fencing provided? Is channel all around the edge of the wall leading to a catch pit / oil trap is provided? The presence of water course / wetland in the vicinity and measures taken to avoid contamination The presence of settlement within 500m Workshop Area Location Area lit. Yes/No (with detailed sketch) Yes/No (with detailed sketch) Details Nos. Deatils Sq.m Unit Date: Contract Package: Ok Not Ok Engineer Remarks

Civil Contractor: Details

e f 2 a b

Sl. No. c

Item

Unit

Details Ok Not Ok

Engineer Remarks

Is impervious base (concrete) with embankment provided? Is channel all around the edge of the wall leading to a catch pit / oil trap is provided? The presence of water course / wetland in the vicinity and measures taken to avoid contamination Provision for collection of used engine oil e.g. barrels Provision for disposal of wash e.g. oil trap Provision of re-use / disposal of collected oil i.e. use in shuttering, disposed to license recycling/contractors/traders Stock Yard for Construction Material e.g. Stone Aggregates, Sand, Cement, Steel Is separate area demarcated for storage of each of the material? Is adequate shed and wall provided around the SY? Storage of Top Soil (Construction Site) The quantity of top soil generated in each of the construction site The plan for top soil re-use onsite

Yes/No (with detailed sketch) Yes/No (with detailed sketch Details Details Details Details

e f g h

3 a b 4 a b

Yes / No Yes / No

cum Detailed

Sl. No. c d 5 a b c d e f g h i j k 6

Item and / or offsite The location for temporary storage The measures for covering the surface of stacked top soil Storage of Construction Waste Material (for grubbing, scarifying etc.) Quantity of grubbed material generated Quantity of usable material Location for temporary storage Quantity of excavated material generated Quantity of usable material Quantity of waste material to be disposed (spoil, debris, etc.) Location for temporary storage Quantity of scarified bitumen Quantity of scarified bitumen to be re-use Quantity of scarified bitumen to be disposed Location for temporary storage Waste Disposal Site/s

Unit plan Ch & Offset Details

Details Ok Not Ok

Engineer Remarks

Cum. Cum. Ch & Offset Cum. Cum. Cum. Ch & Offset Cum. Cum. Cum. Ch & Offset

Sl. No. a b c d e f g h i

Item Location of disposal site/s Distance/s from construction site Land use & type of land of disposal area Water table at disposal area The details of natural drainage and water bodies near disposal area Area of disposal site/s Capacity of disposal site/s Provision of lining impervious layer

Unit Name & Ch. Km Details m Detailed sketch Sq.m Cum. Details Details

Details Ok Not Ok

Engineer Remarks

Provision of top cover with top soil to integrate with surrounding and proposed reinstate plan Details to be attached:

1) Layout plans of SY, Storage of Hazardous Substances, Workshop area and Waste Disposal area 2) Photographs showing pre-condition of the areas Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

BORROW AREA OPERATION AND MANAGEMENT

(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: Borrow Area No.: Location (Ch. & offset): Item Capacity of borrow area Total quantity of earth excavated Quantity of top soil excavated Location of top soil storage Location where top soil re-laid / used Distance from storage site Quantity re-laid /used Quantity of waste material generated in borrow area Location and details of area for disposal of waste material from borrow areas Distance of disposal site from the borrow areas Dust suppression measures Unit Cum. Cum. Cum. km Cum. Cum. Date: Contract Package: Engineer Remarks

Civil Contractor: Dist. from Const. Site: Details Ok

Not Ok

km Adequate/ inadequate Yes/No

Problem of water stagnation Measures adopted for control of soil erosion Details to be attached: 1) Borrow area location map 3) Photographs showing environmental mitigation measures Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

QUARRY AREA OPERATION AND MANAGEMENT

(Reporting by Contractor to CSC) Construction Stage Report: Monthly : Supervision Consultant: Civil Contractor: Quarry Area No. Location (Ch. & offset): Item Capacity of borrow area Total quantity of earth excavated Quantity of top soil excavated Location of top soil storage Location where top soil re-laid / used Distance from storage site Quantity re-laid /used Quantity of waste material generated in borrow area Location and details of area for disposal of waste material from borrow areas Distance of disposal site from the borrow areas Dust suppression measures Unit Cum. Cum. Cum. km Cum. Cum. Details Ok Not Ok Date: From: To: Contract Package: Dist. from Const. Site: Engineer Remarks

km Adequate / inadequate Yes/No

Problem of water stagnation Measures adopted for control of soil erosion Details to be attached: 1) Quarry area location map 4) Photographs showing environmental mitigation measures Certified that the furnished information is correct and all relevant information as required is attached. Contractors Rep: CSCs Field Engineer: CSCs RE

TRANSPORTATION OF MATERIAL
(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: Item Civil Contractor: Unit Details Ok Quantity of material transported from BA and QS to the SY / Construction site and waste Cum. material to disposal sites Quantity of waste material transported to Cum. disposal sites Number of trucks used Cum. Number of trucks having side and tailboard Cum. and used tarpaulin cover (as per Specification) Whether water is spraying to control fugitive Yes/No dust during loading of transport vehicle (details if No) Frequency of water spray on non-metal haul No. of times road in a day Whether all the transport vehicles possess Yes/No valid Pollution Under Control Certificates (details if No) Whether all dust/mud or other extraneous materials dropped by the transport vehicle or Yes/No their tyres on any existing roads & highways (details if No) or on new roads which are part of the work are immediately cleared by the Contractor Any other environmental nuisance arising out of material transportation Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE Not Ok Date: Contract Package: Engineer Remarks

STORAGE AREA MANAGEMENT

(Reporting by Contractor to CSC) Construction Stage Report: Monthly : Supervision Consultant: Sl. No. 1 a Item Date: Contract Package: Details Ok Management of Storage area for Hazardous Substances Whether all the storage tanks / drums have proper label on content, and with cautionary note i.e. Hazardous & Handle Yes / No with Care in Red colour on fluorescent yellow background. Whether filling and refueling is strictly Yes/No controlled (details if No) Whether all valves and trigger guns are Yes/No resistant to unauthorized interference and (details if vandalism No) Whether all valves and trigger guns are Yes/No turned off and securely locked when not (details if in use No) Whether channel all around the edge of Yes/No the wall leading to a catch pit / oil trap is properly maintained Whether catch pit / oil trap is properly Yes/No functioned (details if No) Whether separated oil is being collected in Yes/No cans, re-used and /or disposed of to the (details if recyclers, traders No) Whether emergency response system i.e. Yes/No Not Ok Engineer Remarks

Civil Contractor: Unit

b c d e f g h

Sl. No.

Item fire extinguisher, emergency vehicle and mobile set, medical care center etc. in place. Details of any incidence of contamination of nearby water body due to oily discharge and action taken Details of any incidence on fire and action taken Stock Yard for Construction Material e.g. Stone Aggregates, Sand, Cement, Steel Whether material is stocked as per IRC Frequency of water spray on fine earth material at SY for control of fugitive emission Whether necessary measures taken to avoid / control uneven spreading of material around the yard Details of any incidence of severe fugitive dust emission due to high wind and action taken Storage of Top Soil (Construction Site) The quantity of top soil generated in each of the construction site The plan for top soil re-use onsite and / or offsite The location for temporary storage The measures for covering the surface of stacked top soil Storage of Construction Waste

Unit

Details Ok Not Ok

Engineer Remarks

i j 2 a b c d 4 a b c d 5

Details Details

Number of times in a day / week Yes/No Details

cum Detailed plan Ch & Offset Details

Sl. No. a b c d e f g h i j k

Item Material (for grubbing, scarifying etc.) Quantity of grubbed material generated Quantity of usable material Location for temporary storage Quantity of excavated material generated Quantity of usable material Quantity of waste material to be disposed (spoil, debris, etc.) Location for temporary storage Quantity of scarified bitumen Quantity of scarified bitumen to be re-use Quantity of scarified bitumen to be disposed Location for temporary storage

Unit

Details Ok Not Ok

Engineer Remarks

Cum. Cum. Ch & Offset Cum. Cum. Cum. Ch & Offset Cum. Cum. Cum. Ch & Offset

Details to be attached: 1) Layout plans of SY, Storage of Hazardous Substances and Workshop area 2) Photographs showing pre-condition of the areas Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

Construction Material Re-Use and Disposal

(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: SMEC Sl. No. 1 a b c d e 2 a b c d e Item Construction Material Generation and Re-Use Total quantity of material generated for clearing & grubbing, excavation, demolition, scarifying etc. Total quantity of material proposed to be reuse Quantity of earth material to be disposed Civil Contractor: Unit Details Ok Not Ok Contract Package: Date: Road Section (Ch.) Engineer Remarks

Cum. Cum. Cum.

Quantity of demolished material to be Cum. disposed Quantity of scarified material to be disposed Cum. Waste Disposal Location of disposal site/s Whether disposal area/s has been properly demarcated Capacity of disposal site/s Quantity disposed Whether bund provided with adequate erosion control measures if disposal area is Name/Ch. /Offset Yes / No Cum. Cum. Yes / No

Sl. No.

Item

Unit

Details Ok Not Ok

Engineer Remarks

f g

located on low-lying area adjacent to natural drainage Whether disposal area is properly leveled and graded Yes / No Details of lining provided for scarifying material Details of surface treatment provided Details

Details

Details to be attached: 1) Sketch showing total disposal area, actual disposal area and any environmental control measures taken Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

Workers Camp Management

(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: Workers Camp No. Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 Item Total No of Labourers Total no of Male Workers Total no of Female workers No of female & male Workers below 14 years of age No of children (below 14 years of age) Whether adequate drinking water is provide Whether adequate water supply provided for bathing and general use Total Nos. of WCs provided Nos. of WC functioning Whether any effluent from bathroom or toilet being discharged on nearby land Whether household solid waste being collected, segregated and disposed properly Whether water stagnation occurs in and Civil Contractor: Location (Ch. & offset): Unit Nos. Nos. Nos. Nos. Nos. Yes/ No Yes/ No Nos. Nos. Yes/ No Yes/ No Yes/ No Details Ok Not Ok Date: Contract Package: Engineer Remarks

Sl. No. 13 14 15 16 17

Item around the camp Availability of First Aid Facility Emergency Vehicle available & functioning Camp visit by Doctor/month No of persons fall sick, type of illness and status of recovery Accident occurred, if any and measures taken

Unit

Details Ok Not Ok

Engineer Remarks

Yes/ No Yes/No No of times Attach details Attach details

Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

Soil Erosion and Sediment Control (Clause 306)

(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: SMEC Sl. No. 1 Item Civil Contractor: Unit Details Ok Not Ok Date: Contract Package: Engineer Remarks

Details of temporary / permanent erosion control Details measures taken during clearing, grubbing and filling / (Attach cutting of embankment (attach plan showing chainagesketch) wise details, as required) 2 Erosion control measures provided for slope of Details embankment (attach plan showing chainage-wise details, (Attach as required) sketch) 3 Measures taken to avoid soil erosion during construction Details of bridges and culverts i.e. dyke, sediment basin, (Attach restricting construction during dry weather only etc. sketch) 4 Whether diversion road for construction of CD has been Yes/ No provided with adequate drainage with proper erosion (Details) control measures at outfall and slope of diversion 5 Details of erosion control measures at waste disposal Details site/s i.e. (give details for each borrow pit) 6 Erosion control measures taken at borrow pit/s (give Details. details for each borrow pit in conjunction with redevelopment plan) 7 Erosion control measures for newly constructed haul Details road for borrow / quarry material transportation i.e. embankment slope treatment, toe drain, sediment trap at outlet etc., as required Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

Drainage Control
(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: Sl. No. 1 Item Details of installed temporary / permanent drainage channels as appropriate together with silt trap / silt retention pond before start of road & CD works (attach plan showing chainage-wise details, as required) Whether all drainage channels and inlet / outlet of CDs are cleared before onset of monsoon and cleared material are disposed on approved site/s Whether clearance of vegetation from invert and banks is restricted to just that area required for the construction of CD/bridges Whether construction removed from drain / stream / river Whether adequate storm water drainage has been provided around the quarry site/s Whether the base of borrow pit/s provided with slope leading to natural drainage in conjunction with redevelopment plan Civil Contractor: Unit Details (Attach sketch) Yes / No Yes/ No Yes/ No Yes/ No Yes/ No. Details Ok Not Ok Date: Contract Package: Engineer Remarks

2 3 4 5 6

Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

Fugitive Dust Emission Control

(Reporting by Contractor to CSC) Construction Stage Report: Supervision Consultant:
Code No. Item 1 Frequency of sprinkling of water on Haul road (times/day) Frequency of sprinkling of water at Borrow site (times/day) Total Quantity of water sprinkled (litres) 2 3 4 5 6 7

Monthly: Civil Contractor:

Date 8 9 10

Date: Contract Package:

Ok Not Ok Engineer Remarks

11

12

13

14

15

Borrow Area

Quarry Site
Frequency of sprinkling of water on Haul road (times/day) Frequency of sprinkling of water at Quarry site (times/day) Total Quantity of water sprinkled (litres)

Crusher Plant
Frequency of sprinkling of water on Haul road (times/day) Quantity of Water Sprinkled (litres) Quantity of Water Sprinkled on Conveyor Belt Quantity of Water sprinkled around site Quantity of Water Sprinkled

Code No.

Item 1 around Crusher Site 2 3 4 5 6 7

Date 8 9 10 11 12 13 14 15 Ok

Engineer Not Remarks Ok

Stock Yard
Frequency of sprinkling of water on Haul road (times/day) Quantity of Water Sprinkled (litres) Quantity of Water Sprinkled around site

Construction site/s of project road, service road, diversion etc.

Frequency of sprinkling of water (times/day) Quantity of Water Sprinkled (litres)

Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

Air, Water and Noise Pollution Control and Monitoring

(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: Sl. No. 1 2 3 4 5 a b c d e Item Locations Installed Capacity Air pollution control measures employed Quantity of water used for sprinkling Details of Air quality monitoring (enclosed monitoring report) Location i.e. dist from plant and direction Date of monitoring Duration of monitoring Instrument/s used Monitored value of parameters SPM PM10 SO2 NOX CO KL Unit Ch. / Offset tph Date: Contract Package: SCU-2 HMP-1 HMP-2 Ok Engineer Not Remarks Ok

Civil Contractor: Details SCU-1

m/dir dd/mm/ yy hr

Sl. No. f 6 7 8 a b c d e

Item

Unit Pb

Details SCU-1

SCU-2

HMP-1

HMP-2

Ok

Engineer Not Remarks Ok

Parameters exceeding permissible limits Further air pollution control measures adopted, if necessary Noise pollution control measures employed Details of Noise Level monitoring (enclosed monitoring report) Location i.e. dist from plant and direction Date of monitoring Duration of monitoring Instrument used Monitoring result in dB(A) Whether exceeding permissible limits Further noise pollution control measures adopted, if necessary Details of safety equipment provided to DT dB(A) NT dB(A) Yes/ No

m/dir Dd/mm/ yy hr

f 9

10

Sl. No.

Item workers at plant site i.e. earplugs, mask etc. Water quality monitoring locations* Details of locations Measures adopted to prevent water pollution Parameters exceeding permissible limits (enclose monitoring report) Further control measures adopted, if necessary

Unit

Details SCU-1

SCU-2

HMP-1

HMP-2

Ok

Engineer Not Remarks Ok

11 12 13 14

WQ-1

WQ-2

WQ-3

WQ-4

15 *

Locations will include water bodies close to WC, SCU, HMP etc. The exact locations will be provided by the Engineer.

Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

Hazardous Material Storage, Handling, Transportation and Disposal

(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: Sl. No. 1 Item Details of hazardous materials used i.e. flammable gas, flammable liquid and toxic chemical and explosive e.g. kerosene, petrol, HSD, explosive etc. Whether isolated storage of hazardous chemical is equal or more than the specified threshold quantities Whether all hazardous materials are stored in clearly labeled containers or vessels Whether all the storage tanks / drums have proper label on content, and with cautionary note i.e. Hazardous & Handle with Care in Red colour on fluorescent yellow background. Whether secondary containment i.e. berm, rising wall with catch pit etc., is provided for storage of liquid hazardous material to prevent contamination of soil, ground water and surface water Whether filling and refueling is strictly controlled Whether all valves and trigger guns are resistant to unauthorized interference Date: Contract Package: Details Ok Not Ok Engineer Remarks

Civil Contractor: Unit

Details Yes / No (Quantity in ton) Yes / No

2 3 4

Yes / No

Yes / No (Details) Yes/No (details if No) Yes/No

Sl. No.

Item

Unit

Details Ok Not Ok

Engineer Remarks

and vandalism 7 Whether all valves and trigger guns are Yes/No turned off and securely locked when not in use 8 Whether concerned authority/s (DC, KSPCB & Chief Inspector of Mines) Yes / No have been reported / notified in case of major accident 9 Whether Permission from Chief Controller of Explosives has been obtained for use of explosive during Yes / No blasting as per Indian Explosive Act and Rules 1984, & the Petroleum Act, 1934 and Rules made thereunder. 10 Contingency plan for cleaning up, storage and disposal of oil, fuel and Details toxin chemical spills 11 Details of Personal Protective Equipments used for handling hazardous Details substances Details to be attached: 1) Layout plans of SY, Storage of Hazardous Substances, Workshop area and Waste Disposal area 2) Photographs showing pre-condition of the areas Certified that the furnished information is correct and all relevant information as required is attached Contractors Rep: CSCs Field Engineer: CSCs RE

Occupational Health and Safety

(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: Sl. No. 1 a b c d e f g 2 a Item Date: Contract Package: Unit Details Ok Personal Protective Equipments (PPE) Details of personal protective equipment (PPE) provided to workers at road construction site Details of PPE provided to surveyor at roadside Details of PPE provided to workers at borrow areas Details of PPE provided to workers at quarry sites Details of PPE provided to workers at crusher plants Details of PPE provided to workers at HMPs Details of PPE provided to workers at wet mix plants Safety Measures During Blasting Whether blasting record being maintained incorporating number of holes made/type of explosive used / firing pattern & sequence with date and time of blast (attach details) Whether explosives is handled by licensed blaster Whether intensity of the charge calculated before use Not Ok Engineer Remarks

Civil Contractor:

Details Details Details Details Details Details Details

Attach Details

b c

Yes / No Yes / No

Sl. No.

Item

Unit

Details Ok Not Ok

Engineer Remarks

d e f

g 3 a b c d e

Whether presence of unfired explosives checked before drilling Whether major blasting is carried out only during prescheduled lean hours say lunch hours Whether competent persons equipped with red flags are posted at possible approaches to stop traffic and passerby with min 500m radius Whether standard warning signal / all clear signal before and after firing is ensured Miscellaneous Whether all the construction vehicle have been fitted with reverse horn and the same is working Whether Barricade / Fencing/ Displaying of danger sign, warning sign byway of red flag /tape/ light etc. provide at each construction zone Whether surrounding area is cordoned during demolition Whether ladder is being used for deep trench Whether presence of underground electrical cable, water supply line, steam /gas line etc verified and disconnected / relocated before start of any excavation Whether electrical cable connection/ water/ steam /gas line etc. disconnected before demolition Whether all electrically operated equipment has proper earthing and connected through ELCB. Whether combustible material kept away from source of heat /fire Whether No Smoking Board / Caution Board displayed for

Yes / No Yes / No Yes / No

Yes / No

Yes / No Yes / No Yes / No Yes / No Yes / No

f g h i

Yes / No Yes / No Yes / No Yes / No

Sl. No.

Item prevention of fire

Unit

Details Ok Not Ok

Engineer Remarks

j k l m n

Whether fire extinguishers kept ready near sites of fabrication, fuel storage and any other sites having potential to catch fire for emergency Whether first aid box is located at construction areas and workers camp with a designated person for administering

Yes / No Yes / No

Whether periodic heath check-up for workers is undertaken Yes / No (attach Doctors certificate) (Attach certificate) Whether emergency vehicle is ready at sites having Yes / No accidental risk i.e. fabrication, blasting, crusher plant, demolition site etc. Whether emergency response and contingency plan Yes / No (ERCP) is in place with clear understanding of who-will(Attach do-what in case of any accident i.e. ACTION TREE ERCP) (attach the same) Whether training / awareness program conducted with Yes / No workers and other field staff for using and maintaining (Attach protective and safety equipments and measures. (Attach details) details, if any)

Certified that the furnished information is correct and all relevant information, as mentioned in this checklist, is attached Contractors Rep: CSCs Field Engineer: CSCs RE

Traffic Management and Safety

(One time reporting on commencement of construction in the Construction zone by Contractor to SC) Construction Stage Report: Supervision Consultant: Sl. No 1 a b c d e f Monthly: Civil Contractor: Unit Compliance OK Details of Construction Zone Length of Construction Zone Distance between this and next construction zone Length of transition sub zone (should be min 100-200m for a speed of 40-50km/hr) Length of work sub zone in urban stretch (should be<=0.5 km) Length of work sub zone in rural stretch (0.5-1.0km) Distance between two work sub zones km km Not OK Date: Contract Package: Engineer Remarks

Item

km km

North / East side 2 a b c Signages in construction zones Sign saying Men at Work 500m km ahead of Transition sub zone Supplementary sign saying Diversion 500m provided Sign saying Road Closed ahead provided Y/N Y/N Y/N

South / West side

Sl. No d e f

Item Compulsory Turn Right/Left sign provided Detour sign placed Sharp Deviation sign placed at end of advance warning sub zone Signage in Transition Sub Work Zone Signage saying Keep Right/Left provided Delineators placed along length of transition Signage in work sub zone Hazard Marker placed where railing for CD structure on diversion starts Barricade on either side of work sub zone Signage in Termination sub zone Sign for indication of end of work zone 2050m from end of termination sub zone

Unit Y/N Y/N Y/N

Compliance OK Not OK

Engineer Remarks

g h

Y/N Y/N

i j k

Y/N Y/N Y/N

Documents to be attached: 1) 2) Sketch of construction zone showing all sub zones and location of signs Format on Acquisition of Temporary Land for diversions to be attached

Certified that the road safety measures have been adopted as specified and as per the direction of the CSC Contractors Rep: CSCs Field Engineer: CSCs RE

Preservation of Cultural Heritage

(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: SMEC Sl. No. 1.a 1.b 2.a 2.b 3.a 3.b 3.c Item* Location (Ch & Offset) Civil Contractor: Description / sub-category Plan for Preservation** Target Date Date: Contract Package: Completion Target Actual Reason for delay if any Completion Date

AS-1 AS-2 HS-1 HS-2 SS-1 SS-2 SS-3 US-Site of Unique Natural Value

* AS-Archaeological site; HS- Historical site; SS- Religious place / sacred site; ** Preservation plan should be approved by the Engineer before implementation Documents to be Attached: 1) Plan for preservation of each of the cultural property located within the ROW

Certified that the road safety measures have been adopted as specified and as per the direction of the CSC Contractors Rep: CSCs Field Engineer: CSCs RE

Environmental Enhancement
(Reporting by Contractor to CSC) Construction Stage Report: Monthly: Supervision Consultant: SMEC Sl. No. BS-1 BS-2 PA-1 PA-2 RA-1 RA-2 WB-1 WB-2 * BS- Bus stops; PA- Parking areas; RA- Rest areas / Eating places; WB- Water bodies within / close to ROW ** The site/s to be enhanced will be identified jointly by Contractor and Engineer and plan for the same should be approved by the Engineer Documents to be Attached: Plan for enhancement measures of each of the site Certified that the road safety measures have been adopted as specified and as per the direction of the CSC Contractors Rep: CSCs Field Engineer: CSCs RE Item Location (Ch & Offset) Date: Contract Package: Target Date Completion Target Actual Reason for delay if any Completion Date

Civil Contractor: Description / sub-category Enhancement Plan