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ATTACHMENT 5 <br /> SITE INCIDENT REPORT <br /> Date of Incident: Time of Incident: <br /> Location of Incident: Project Name- <br /> Project Number: <br /> Type of Incident* (check those that apply): <br /> "Near Miss" Vehicle Accident <br /> Underground Property Damage Fire <br /> Above-ground Property Damage Evacuation <br /> Chemical Exposure Regulatory Agency <br /> Inspection or Violation <br /> Other(descnbe) <br /> *Submit copy of Health & Safety Plan and Attachments for field-related incidents <br /> Description of Incident: <br /> Cause of Incident: <br /> Action Taken: <br /> Future Corrective Action: <br /> Estimated Amount of Damage: <br /> Investigator Name Signature <br /> Date <br /> Principal-in-Charge Signature <br /> • Date <br /> cc Corporate Health & Safety, Vice-president of Operations, & Corporate Contracts/Admin within 24 <br /> hours of incident <br />