Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Job information
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Energized
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De-Energized
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Overhead
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Underground
Equipment
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Bucket Truck
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Digger Truck
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Skid loader
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Backhoe
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Mini-hoe
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Pickup
PPE
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Hi-viz shirt or vest
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Single shot
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Cover up
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Grounds
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Barricades
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Traffic control
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Hard hats
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Safety glasses
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Rubber gloves or sleeves
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Fall protection
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Pictures
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Comments
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Sign