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Health and Safety Plan <br /> 1319 & 1327 South Madison Street, Stockton,CA <br /> 432770 <br /> IIPP FORM I: REPORT OF UNSAFE CONDITION OR HAZARD <br /> DEPARTMENT: <br /> I. UNSAFE CONDITION OR HAZARD <br /> HAZARD EVALUATION:(CIRCLE ONE) IMMINENT SERIOUS MODERATE/LOW <br /> Name:(Optional) Job No: <br /> Title: Location of Hazard: <br /> Building: f Floor: Room: <br /> Date and time the condition or hazard was observed: <br /> Descdpdon of unsafe condition or hazard: <br /> what changes would you recommend to correct the condition or hazard? <br /> Employee Signature:(Optional) Date: <br /> II. MANAGEMENT/SAfETy COMM WEE INVESTIGATION <br /> Name of person Investigating unsafe condition or hazard: <br /> Results of Investigation(What was found?was condition unsafe or a hazard?):(Attach addltlonaI <br /> sheets if necessary. <br /> Proposed action to be taken to correct hazard or unsafe condition:(Complete and attach a Hazard <br /> Correction Report,IIPP Form Z) <br /> Signature of Uvestigating Party: Date: <br /> AE1 I/ua Rh&Safety,Injury&111ngs Preventlan Program Page 12? <br /> It�nsed 6118(201.3 <br />