Division of Occupational Safety and Health
Address of the District Office (on the citation)
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) ____________________________________________________