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					                                                                           PMA LOG NO.
                       State of New York - Department of Labor
                                                                           INSPECTION NO.
                       DIVISION OF SAFETY AND HEALTH
                       Public Employee Safety and Health Bureau           APPROVED                   DISAPPROVED
                                                                          If Approved, Enter
                                                                          New Abatement Date
                                                                           DECISION DATE:
                                                                           SIGNATURE:
                                                                           ABOVE SPACE FOR OFFICE USE ONLY
                      PETITION FOR MODIFICATION OF ABATEMENT DATE
 1. NAME AND ADDRESS OF PETITIONER (e.g., Town of Guilderland, Department of Motor Vehicles, etc.)



 2a. NAME OF PETITIONERS REPRESENTATIVE AND TITLE                            2b. TELEPHONE NUMBER



 3. LOCATION (ADDRESS) OF PLACE CITED FOR VIOLATION (INCLUDE BUILDING NAME AND ROOM NO., IF APPLICABLE)




 4. STANDARD, REGULATION OR SECTION OF THE ACT VIOLATED (From Notice of Violation and Order to Comply) FOR
    WHICH PETITIONER SEEKS MODIFICATION OF ABATEMENT DATE (ATTACH A COPY OF THE PAGE(S) OF THE NOTICE
    OF VIOLATION AND ORDER TO COMPLY WHICH PERTAIN TO YOUR VARIANCE REQUEST)

 5a. PROVIDE DETAILED EXPLANATION FOR INABILITY TO COMPLY WITH THE NOTICE OF VIOLATION BY ABATEMENT
     DATE (Attach additional sheets if necessary)


 5b. PROVIDE STATEMENT(S) BY QUALIFIED INDIVIDUALS WHO HAVE FIRST HAND KNOWLEDGE OF THE FACTS,
     EXPLAINING THE REASONS FOR INABILITY TO COMPLY WITH THE ABATEMENT DATE. (USE SEPARATE SHEETS OF
     PAPER). ATTACH ANY SUPPORTING DOCUMENTATION SUCH AS A LETTER FROM A CONTRACTOR, ETC. GIVE THE
     NAME AND TITLE OF THE PERSON(S) MAKING THE STATEMENT.




 6. DATE WHEN YOU EXPECT TO BE ABLE TO COMPLY WITH ABATEMENT DATE AND WHAT STEPS YOU HAVE TAKEN
    OR WILL TAKE, WITH DATES SPECIFIED, TO COME INTO COMPLIANCE WITH THE STANDARD.(Attach additional sheets
     if necessary)




SH 971 (6/05)
7. EXPLAIN ALL INTERIM STEPS YOU HAVE TAKEN OR WILL TAKE WITH SPECIFIC DATES, TO PROTECT EMPLOYEES AGAINST HAZARDS
   WHICH HAVE BEEN CREATED BY THE VIOLATIONS CITED




8a. A COPY OF THIS PETITION WAS POSTED ON                                         (DATE) IN A CONSPICUOUS PLACE WHERE ALL
AFFECTED EMPLOYEES WILL HAVE NOTICE THEREOF.
SUCH PETITION SHALL REMAIN POSTED FOR A PERIOD OF TEN (10) WORKING DAYS, IF APPROPRIATE.


8b. A COPY SHALL BE SERVED ON THE AUTHORIZED REPRESENTATIVE(S) OF THE AFFECTED EMPLOYEES IN
ACCORDANCE WITH PART 804.4 OF TITLE 12 OF THE 0FFICIAL COMPILATION OF CODES, RULES AND REGULATIONS OF
OF THE STATE OF NEW YORK ( 12NYCRR PART 804).

PROVIDE EVIDENCE OF SERVICE UPON THE AUTHORIZED REPRESENTATIVE OF AFFECTED EMPLOYEES. IN
PERSONAL SERVICE, SUPPLY THE NAME AND TITLE OF THE ELECTED OFFICER SERVED.

NAME                                           TITLE                                      UNION


NAME                                           TITLE                                      UNION

NAME                                           TITLE                                      UNION
IF SERVICE IS BY CERTIFIED MAIL, ATTACH A PHOTOCOPY TO THIS PETITION OF THE ENVELOPE(S) AND RETURN
RECEIPT(S) PRIOR TO MAILING SHOWING THE NAME(S) AND ADDRESS(ES) OF THE INDIVIDUAL(S) BEING SERVED.

9. I CERTIFY THAT THE INFORMATION PROVIDED IN THIS PETITION IS COMPLETE AND ACCURATE AND AFFECTED
   AUTHORIZED REPRESENTATIVES HAVE BEEN NOTIFIED (ITEM 8b).
  PETITIONER’S REPRESENTATIVE SIGNATURE:                                                                  DATE:

NOTE: A Petition For Modification Of Abatement Date must be filed with the district office of the New York State Department of
Labor that issued the Notice of Violation no later than the close of the next working day following the date on which the
abatement was originally required. A late petition must be accompanied by the petitioner’s statement of exceptional
circumstances explaining the delay.
Affected employees or their representatives have the right to file an objection to the petition in writing with the District Office.
Failure to file such objection within ten (10) working days of the date of posting of this petition or of service upon an authorized
representative shall constitute a waiver of any further right to object to this petition.

RETURN 3 COPIES OF THIS PETITION TO THE NEW YORK STATE DEPARTMENT OF LABOR, DIVISION OF SAFETY AND
HEALTH. RETAIN ONE COPY FOR YOUR FILES.


ALBANY                           BINGHAMTON                    BUFFALO                       GARDEN CITY
Gov. W. Averell Harriman         44 Hawley Street - Rm. 901   65 Court Street - Rm. 400     400 Oak Street - Suite 101
State Office Campus-Bldg 12      Binghamton, NY 13901         Buffalo, NY 14202             Garden City, NY 11530
Albany, NY 12240                 (607) 721−8211               (716) 847−7133                (516) 228−3970
(518) 457−5508 - Rm. 158


ROCHESTER                        NEW YORK CITY                 SYRACUSE                      UTICA                 WHITE PLAINS
109 S. Union St. Rm. 402         345 Hudson St. Rm 7023        450 S. Salina St. Rm 401      207 Genessee St.     120 Bloomingdale Rd.
Rochester, NY 14607              PO Box 683                   Syracuse, NY 13202            Utica, NY 13501       White Plains, NY 10605
(585) 258−4570                   New York, NY 10014-0705      (315) 479−3212                (315) 793−2258        (914) 997−9514 - Rm. 255
                                 (212) 352-6087                                                Rm. 703A