Cal. Code Regs. Tit. 8, div. 1, ch. 3.2, subch. 2, art. 1.5, app A to Section 340.4
(Name), District Manager
Division of Occupational Safety and Health
Address of the District Office (on the citation)
[Company's Name]
[Company's Address]
The hazard referenced in Inspection Number [insert 9-digit #] for violation identified as:
Citation [insert #] and item [insert #] was corrected on [insert date] by: __________
Citation [insert #] and item [insert #] was corrected on [insert date] by: __________
(NOTE: Follow sample format for each citation or item)
I attest that the information contained in this document is accurate.
______________________________________________
Signature
_____________________________________________
Typed or Printed Name
Note: For serious violations the submittal must be made under penalty of perjury. For Example:
"I declare under penalty of perjury the foregoing is true and correct. Executed this __________ day of (month) in the city of ____________________, California.
__"___________________________________________
(Signature)
Cal. Code Regs. Tit. 8, div. 1, ch. 3.2, subch. 2, art. 1.5, app A to Section 340.4