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County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx <br /> Page 75 <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 />3.12 Forms <br />LOCKOUT POLICY & PROCEDURE <br />CONTRACTOR/VENDOR ACKNOWLEDGEMENT <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />The undersigned has received the Department of Public Works policy and procedure and agrees to <br />abide by it during work on behalf of the County, whether such work is directly supervised by the <br />County, or not. <br /> <br />The Department of Public Work’s Lockout Policy & Procedure is to be followed whenever work is <br />performed on County property. <br /> <br /> <br /> <br />Name of Contractor (Print) Issuing Division (Print) <br /> <br /> <br />Signed By Signed By <br /> <br /> <br />Title Title <br /> <br /> <br />Date Date <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Original: Issuing Division <br />Copy: Contractor/Vendor <br /> <br /> <br /> <br />