Accelerated Carbon Capture and Sequestration (ACCS) Project.

SAFETY VIOLATION NOTICE

Date:
From: HSE DEPARTMENT
TO: The Superior of the concerned Violator
Ref No: SVN/HSE/ACCS/01

Given below are violation details of Safety rules / Site safety Instructions committed by an
employee working at ACCS Project.

Details of Violator
Name: Emp Id:
Occupation: Company Name:
Location: Time:
Supervisor/Engineer/Job Tittle: Tele:

Details Of Violation(s):

Immediate Action Taken:

Offence (s) (Specify):

Miner (1st/ 2nd/ 3rd): - Major (1st/2nd/3rd): - Dismissal: -

Previous Violation(s): -

Action recommended: Written Warning ________ Counselling_________

Suspension_________ Dismissal_________

Signature of HSE Supervisor: -

Signature of Construction Manager: -