Cal. Code Regs. Tit. 8, div. 1, ch. 3.2, subch. 2, art. 1.5, app B to Section 1903.19
(Name), District Manager
Division of Occupational Safety and Health
Address of the District Office (on the citation)
[Company's Name]
[Company's Address]
Check one:
Abatement Plan [ ]
Progress Report [ ]
Inspection Number
Page __________ of ____________________
___________________________
Citation Number(s) * ___________________________
Item Numbers_____________________________________________
| Action | Proposed Completion Date (for abatement plans only) | Completion Date (for progress reports only) |
1. _____________________________________________________
2. _____________________________________________________
Date required for final abatement:
I attest that the information contained in this document is accurate. (NOTE: For serious violations the document must be submitted under penalty of perjury. See Appendix A, above)
___________________________
Signature
___________________________
Typed or Printed Name
___________________________
Name of primary point of contact for questions:________________________________________
[optional]
Telephone Number________________________________________
* Abatement plans or progress reports for more than one citation item may be combined in a single abatement plan or progress report if the abatement actions, proposed completion dates, and actual completion dates (for progress reports only) are the same for each of the citation items.
Cal. Code Regs. Tit. 8, div. 1, ch. 3.2, subch. 2, art. 1.5, app B to Section 1903.19