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Te Finish Date Supervisor Phone No. Emergeny No. 911 ACC Phone No. Safety Officer (916) 708-3983 Work to be completed with OK to Work: Eligible Worker Clearance Holders Description of Work Potential Hazards: (Check those that apply) Flooding Confined Spaces Skin Irritants High Noise Levels Fall Potential Ionizing Radiation Toxic Material Excavation Hazard Adjacent Work Elevated Load or Work Lifting Hazards Inadequate Ventilation Difficult Access Water/Drowning Hazard Shoring/Sloping En.

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