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STATE OF CALIFORNIA <br />DEPARTMENT OF INDUSTRIAL RELATIONS <br />DIVISION OF OCCUPATIONAL SAFETY AND HEALTH <br />EMPLOYERS SIGNED RESPONSE TO NOTICE OF INTENT TO ISSUE SERIOUS VIOLATION <br />(PLEASE ADD ADDITIONAL PAGES AS NECESSARY) <br />I have reviewed the foregoing statement and declare that it is true and correct to the best of my knowledge and all submitted <br />documentation is accurate. <br />Employer: <br />Signature: Date: <br />Name: Title: <br />OFFICE USE ONLY <br />The above statement and attached documentation has been received and considered prior to issuance or non -issuance of proposed <br />citation. <br />Division Engineer/Industrial Hygienist: Date: <br />District Manager: Date: <br />Comments: <br />2 4 G0994 ' 034-12 314995093 <br />Region District SEYIH Identification No. Optional Report No. CAIJOSHA I Report No. <br />CAL/OSHA I BY (1/10) <br />