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3.12 Forms <br /> LOCKOUT POLICY & PROCEDURE <br /> CONTRACTOR/VENDOR ACKNOWLEDGEMENT <br /> Instructions:This form is to be used whenever a County contractor or vendor performs work for the <br /> Department of Public Works and will need to lockout energy sources in order to perform the work <br /> safely. Provide contractor a copy of the Department of Public Works Equipment Lockout Policy& <br /> Procedure(policy plus list of equipment covered under policy). <br /> The undersigned has received the Department of Public Works policy and procedure and agrees t <br /> abide by it during work on behalf of the County,whether such work is directly supervised by the <br /> County,or not. <br /> The Department of Public Work's Lockout Policy&Procedure is to be followed whenever work is <br /> performed on County property. <br /> Name of Contractor(Print) Issuing Division(Print) <br /> Signed By Signed By <br /> Title Title <br /> Date Date <br /> Original: Issuing Division <br /> Copy: Contractor/Vendor <br /> County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx <br /> Page 75 <br />