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Egulation (OHSR), Part 19. Cont ra c t or t o c om ple t e t his se c t ion (please print) Name of customer/contractor Number Sequential number assigned Mailing address City Phone number (include area code) Fax number (include area code) Email address Date that workers and/or equipment will be working in proximity to energized electrical equipment or conductors Time (hh:mm) Date (yyyy-mm-dd) Time (hh:mm) Date (yyyy-mm-dd) TO: FROM: Nature of work Construction Washing Other (specify) Roof.

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