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IF YOU WERE DRIVING A PRIVATE VEHICLE ON COUNTY BUSINESS,ANSWER THESE ADDITIONAL QUESTIONS: <br /> Are You Authorized to Drive a Private Car on County Business? F Yes F No <br /> Do You Have Proof of Personal Insurance on File with the County? f—Yes j No <br /> Where May Vehicle be Seen(Shop or Address)? City <br /> Registered Owner of V chicle(If Other Than Employee) Phone Number <br /> Address City Zip Code <br /> Vehicle Insured By Po icy Num tt <br /> 1.USE THE SYMBOLS BELOW TO COMPLETE THE DIAGRAM <br /> 2.GIVE STREET NAME,DIRECTIONS AND LOCATION OF OBJECTS INVOLVED <br /> Conditions: 3. SKETCH IN ANY OTHER SIGNIFICANT OBJECTS OR LANDMARKS <br /> A Dry 4. PUT NORTH ARROW ON DIAGRAM <br /> B Wet 5.NUMBER EACH VEHICLE(MAKE YOURS 01)AND SHOW DIRECTION <br /> C Sncrw/lcy OF TRAVEL BY ARROW <br /> D Slippery(Muddy,Oil,Etc.) <br /> Weather: STOP SIGN <br /> A Clear <br /> B Cloudy <br /> C Raining 0 SIGNAL <br /> D SnowingU <br /> E Fog 04 RAILROAD <br /> F Other <br /> ROAD SURFACE: X POINT OF IMPACT <br /> LIGHTING: P PEDESTRIAN <br /> Please show on diagram <br /> how accident happened. <br /> Give street names. <br /> Indicates points of compass <br /> / N.E.S.W. <br /> DESCRIPTION OF ACCIDENT <br /> Please Write Legibly.Explain in Your Own Words What Happened.Use Extra Pages if Necessary <br /> certify a e information in this report is to the best or my knowledge true and correct: <br /> Date Employee Signature <br /> Supervisor's Name(Please Print) Supervisor's Signature <br /> S&.T 207 Rev 1-07 <br /> San Joaquin County <br /> Department of Public Works <br /> County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 35 <br />