Housing Occupancy Certificate — Migrant and Seasonal Agricultural Worker Protection Act U.S. Department of Labor Employment Standards Administration Wage and Hour Division OMB Number: 1215-0158 Expiration Date: 05-31-2011 NOTE: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. A. IDENTIFYING INFORMATION 1. Location of Housing Inspected: Description of Housing Units and Number of Units: 2a. Name and Address of Owner of Housing Units: 3a. Name and Address of Individual(s) in Charge: b. Phone: b. Phone: 4a. Name and Address of Farm Labor Contractor, if Any: 5. Date Inspection was Requested: 6. Expected Dates of Occupancy From: To: b. Registration No.: B. CERTIFICATION: For Completion By Agency Personnel Conducting Housing Inspection The housing identified above has been inspected by the undersigned and found to meet the substantive safety and health standards prescribed in one of the following Department of Labor regulations. 29 C.F.R. § 1910.142 Occupational Safety and Health Administration Regulations 20 C.F.R. Part 654 Employment and Training Administration Regulations Date of Inspection: Date Certificate Expires: Maximum Occupancy: The definition of substantive safety and health standards is given in 29 C.F.R. § 500.133. Special Conditions (If none, write “None”): District Office Address: (Signature and Title of Person Issuing Certificate) (Date Issued) Important Notice: A copy of this certificate must be posted at the site of the housing identified above. This certificate is valid for one year from the date of issuance. If after one year from the date of this certificate the property identified above is to be utilized to house migrant workers, a new certificate must be requested. The original of this certificate must be kept as a record for three years from the date of issuance. This inspection certificate does not relieve any person from compliance with any applicable State, county or local ordinance. Receipt and posting of this certificate of occupancy does not relieve the persons who own or control this facility or property from the responsibility of ensuring that such facility or property meets the applicable State and Federal safety and health standards. Once such facility or property is occupied, such person shall supervise and continually maintain such facility or property to ensure that it remains in compliance with the applicable safety and health standards. Public Burden Statement Public reporting burden for this collection of information is estimated to average 4 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information, and maintaining the records. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Administrator, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. American LegalNet, Inc. www.FormsWorkflow.com Form WH-520 Rev. June 2008