California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
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)