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<br /> <br /> <br /> <br />CONTRACTOR AMMONIA QUALIFICATION FORM <br /> <br />Company Name: <br />Contact Name: <br />Address: <br />City/State/Zip: <br />Phone: <br /> <br />Contractor Responsibility Statement <br /> <br />Contractors (and their subcontractors) working for Leprino Foods - Tracy must: <br /> <br />· Make sure that their employees are trained in work practices necessary to <br />safely perform their jobs in the presence of hazardous chemicals. <br />· Make sure that each contract employee follows all of Leprino Foods - Tracy <br />safety rules. <br />· Advise Leprino Foods - Tracy Process Safety Management (PSM) program <br />Implementer of any unique hazards caused by the contractor's work or of <br />hazards found by the contractor’s employees. <br /> <br />This form is intended to verify that the contractor’s obligations have been met. <br /> <br />1. CONTRACTOR EXPERIENCE <br /> <br />Has your company worked with ammonia refrigeration <br />systems? Yes No <br /> <br />Does your company have experience with the requirements <br />of the PSM/RMP Programs? Yes No <br /> <br /> Explain: <br /> <br /> <br /> <br /> Fax: Other Phone: