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� I <br /> ACKNOWLEDGMENT OF INSTRUCTION <br /> All Terracon personnel are required to sign the following acknowledgment of instruction form <br /> prior to conducting project activities. This acknowledgment is not a waiver. It is the primary <br /> method used in compiling environmental experience and contaminant exposure records for <br /> Terracon personnel. Upon written request, a copy of your environmental work record will be <br /> provided by the Corporate Safety and Health Manager. <br /> I understand that this project involves the investigation of a project site with potential petroleum <br /> hydrocarbon contamination. I have read this Safety and Health Plan and have received <br /> instructions for safe work practices, personal protective equipment and air monitoring <br /> requirements. I further understand that if I encounter unanticipated contamination I am to leave <br /> the site and immediately notify the Project Manager and Corporate Safety and Health Manager <br /> of conditions discovered. <br /> PROJECT NAME: <br /> TERRACON JOB #: <br /> Name (Please Print) Signature Date <br /> i <br /> i <br /> PERSONAL PROTECTIVE EQUIPMENT UTILIZED: <br /> I <br /> LEVEL D LEVEL D MOD. _LEVEL C <br /> Safety briefing performed by: Date: <br /> i <br /> PETROLEUM CONTAMINANT(S): <br /> I <br /> AIR MONITORING RESULTS (Attach separate page if required.) <br /> 2 } <br /> i <br />