Employers Signed Statement Of Abatement Of Regulatory And-Or General Violations {CAL-OSHA 160}

STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF OCCUPATIONAL SAFETY AND HEALTH 1. Return to: EMPLOYER'S SIGNED STATEMENT OF ABATEMENT OF REGULATORY AND/OR GENERAL 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. Please notify the Division as soon as these conditions have been corrected by returning this completed form. Your response by completing, signing and mailing this form to the issuing office on or before the compliance date may avoid a follow-up inspection of your facilities. Failure to timely complete and return this form may result in issuance of a citation and civil penalty for violation of 8 CCR 340.4(c). NOTE: This form does not serve as a request for a time extension. If there are serious problems beyond your control that prevent meeting a specified abatement date, contact the Division early, well within the 15-day limit allowed for an appeal. This signed statement or a summary shall be posted for three (3) working days at or near each place the regulatory and/or general violation(s) referred to in the citation occurred. 4. PLEASE COMPLETE AND MAIL BY ************************ 200 5. LIST THE SPECIFIC MEASURES & EQUIPMENT TAKEN TO CORRECT EACH CITATION & ITEM NUMBER OF THE UNSAFE CONDITIONS AND DATE OF ABATEMENT 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 This certifies that all the unsafe conditions listed in the Division's Citation dated corrected and all submitted abatement information is accurate. Signature: Name: Date: Title: OFFICE USE ONLY Division Engineer/Industrial Hygienist: District Manager: [ ] Close / Comments: Date: Date: have now been 7. 8. 9. Region District Inspection No. ID No. Cal/OSHA Rpt.No. 10. Date mailed or delivered: FY CAL/OSHA 160 (09/01/00) American LegalNet, Inc. www.FormsWorkflow.com