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work plan for soil remediation, sampling and analysis plan, site ...

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(Use Extra Pageif Needed).--%scribo the InjuryAllnoss in Detail; lndbate Part of Body AffectedName of Object/Substance Which Directly Injured ErnpbyeeHasNiff Empbyee Se& Treatment? a Yes 0 No Did Employee Die? a Yes Q NoName/Addressal HaspiWOouarDescribe Treatment GivenWas Empbyoe Able To Return To Work? a Yes QNaIf YES: 0 Re@ar Work Cl Work with Restricted ActivitiesR4strictianIf NO: Due Last Time Bqan Oat&Es& Date To Return. .: identify Personal Pmteclfvo Equipment Used by Injured Emplayee1. What Trafning at lns~~ctfon Had Been Given?How Could This Accident Have Boon Prevented?CarrectivektienSiinzitureSignature-.(SupvrlManager)(Safety Offkar)DateOateSignature(Pmj. Manager)Oate.I~IBUTlON Original To: Diiision Secretary at Employee’s Home OfficeCopy To: Q Corporate Health L Safety c1 Regbnal Health & Safety Manager0 Projed Manager 0 Site Safety Filec* -- -.-----, ----.-

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