Chapter 3.2. California Occupational Safety and Health Regulations (CAL/OSHA)
Subchapter 2. Regulations of the Division of Occupational Safety and Health
ARTICLE 1.5 Employer’s Declaration of Abatement and Other Documentation of Abatement—Employee Notification—Posting Requirements.

Appendix A to Section 340.4—Sample Abatement—Certification Letter (Non-mandatory)

(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)

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