(Name), Administrator
S. C. Department of Labor, Licensing & Regulation OSHA
Address of the Area Office (on the citation)
[Company's Name]
[Company's Address]
The hazard referenced in Optional Report No. (insert 6-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:
_________________________________________________________________________________________
___________________________________________________________________
Citation [insert #] and item [insert #] was corrected on [insert date] by:
_________________________________________________________________________________________
___________________________________________________________________
Citation [insert #] and item [insert #] was corrected on [insert date] by:
_________________________________________________________________________________________
___________________________________________________________________
Citation [insert #] and item [insert #] was corrected on [insert date] by:
_________________________________________________________________________________________
___________________________________________________________________
I attest that the information contained in this document is accurate.
______________________________________________________________________________
Signature
______________________________________________________________________________
Typed or Printed Name
S.C. Code Regs. ch. 71, art. 1, subart. 4, app A