STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF OCCUPATIONAL SAFETY AND HEALTH 1. Return to: EMPLOYER'S SIGNED STATEMENT OF ABATEMENT OF SERIOUS VIOLATIONS 2. EMPLOYER: ADDRESS: Street City State Zip 3. The law requires that violations observed during the inspection/investigation completed on of the place of employment located at be corrected within the time limit specified. Labor Code 6320(b), requires that you submit this signed statement under penalty of perjury which describes the measures for abating each citation which alleges a serious violation. If the signed statement is not received within 10 working days after the end of the period fixed for abatement, the Division will be required to revoke any adjustments to the civil penalty based upon the assumption that you will abate the violation. This action will result in a doubling of the civil penalty for serious violations. If you have filed a timely appeal with reference to a particular citation, the abatement date is stayed during the appeal process and the Signed Statement need not be submitted at this time. In addition, if there are problems beyond your control that prevent meeting a specified abatement date, contact the Division early so that a request for extension can be considered. This signed statement shall be posted THIS FORM MUST BE RECEIVED AT THE ABOVE ADDRESS ON OR BEFORE for three (3) working days at or near each place the serious violation referred to in the citation occurred. 4. ************************ 5. DESCRIBE AND LIST THE SPECIFIC MEASURES & EQUIPMENT TAKEN TO ABATE EACH SERIOUS VIOLATION Citation Number Number of Instances Measures Taken to Abate Serious Violation Abatement Date 6. [ ] Continued on additional page All affected employees and their representatives have been informed about abatement activities referenced in this document in conformance with 8CCR Section 340.4(g). oYes oNo I have reviewed the foregoing statement and declare under penalty of perjury that it is true and correct to the best of my knowledge and all submitted abatement information is accurate. Executed at Signature: Name: , California by Date: Title: OFFICE USE ONLY Division Engineer/Industrial Hygienist: District Manager: [ ] Close / Comments: Date: Date: 7. 8. 9. Region District Inspection No. ID No. Cal/OSHA Rpt.No. FY CAL/OSHA 161 (09/01/00) American LegalNet, Inc. www.FormsWorkflow.com 10. Date mailed or delivered: