Self-Inspection Checklist

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First and Last Name

Select a date

Physical or Prperty Damage

Damage to Property

Injury?

No Damage to People or Property

Please explain all "No" Answers

Thank you for submitting this Near Miss Form. The Safety Committee will be reviewing it.

Gaston Fire District
102 E. Main St.
Gaston, OR. 97119
P 503-985-7575
F 503-985-7382

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